Hidden Lakes Senior Living Community
1006 33rd St, Vero Beach, FL 32960 · For profit - Limited Liability company · 24 certified beds · (772) 567-5248 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.8% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 2.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 14.4% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents with pressure ulcers | 3.1% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.4% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.4% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.6% | 9.1% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.2% 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 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.7% 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 41 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.2%CMS range 57.6–75.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.5–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 10.6%CMS range 6.6–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 24 beds and averages 20.2 residents a day — about 84% occupied, or roughly 4 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.48 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.13 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.14 hrs/resident/day on weekends vs 4.90 on weekdays — 16% thinner on weekends. RN hours go from 1.56 to 1.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Fcited before2026-02-05 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to follow the menu for 1 of 3 observed meals, as evidenced by the failure to follow the recipes for the main entree of Beef Quesadilla and the alternate entree of Savory Baked Chicken Thigh. This resulted in a food complaint by 2 of 10 sampled residents, Resident #7 and a resident who requested to be anonymous. The Certified Dietary Manager (CDM) also added mashed potatoes and gravy to the alternate meal without following their documented process.The findings included:1) Review of the policy Menus and Adequate Nutrition with a Copyright of 2025, documented in part, Policy Explanation and Compliance Guidelines: . 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Review of the policy Altering Food Recipes dated 07/08/22, documented in part, Policy: All recipe alterations must be approved by the facility's Registered Dietitian (RD) before implementation. Documentation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-02-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 18 residents who ate food by mouth. The census at the time of survey was 18. The findings included:An observation of the kitchen was conducted on 02/02/26 beginning at 10:00 AM with the Certified Dietary Manager (CDM). The following findings were noted and confirmed by the CDM:a) The beverage dispenser had a brown thick liquid substance in the tray.b) A brown liquid spillage and loose dry macaroni noodles were noted on the clear plastic cover of a box in the dry storage area, that contained three cans of chicken and dumplings.c) There was an opened bag of macaroni noodles in the dry storage area.d) Food crumbs were noted along the side of the clean plastic cups stored on a three shelf rolling cart. e) There was debris and food crumbs on the floor at the side of the ovens.f) There was debris and food crumbs on the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-02-05 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to maintain the dumpster area in a clean and sanitary condition as evidenced by the failure to dispose of garbage and refuse properly. This failure had the potential to attract pests.The findings included:An observation of the dumpster area was made with the Certified Dietary Manager (CDM) and the Environmental Service Director on 02/05/26 at 10:51 AM. There were two dumpsters located at the back of the building with a wooden fence around them. On the ground in front of the fence, and inside the fence in front of each dumpster was spilled debris and food. Photographic evidence obtained. The Environmental Service Director stated, I'll get someone to clean this up.
- Potential for harm · E2026-02-05 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to service food at a safe and palatable temperature for 2 of 3 sampled residents who were served milk during the lunch meal on 02/04/26, Residents #3 and #16, and as evidenced by kitchen processes resulting in resident complaints of cold food by Resident #7, #2, and #10.The findings included:1) A tray line observation was made on 02/04/26 beginning at 11:35 AM. Upon arrival in the kitchen two small open carts and two large open tray carts were noted with the resident's food trays and meal tickets set up on the four different carts. Staff E, Dietary Aide, explained one of the large carts was for the skilled nursing facility (SNF) and the other for the assisted living facility (ALF). Staff D, cook, explained one of the small carts was for the pureed meals and the other for the mechanically altered meals. The cook further explained she preferred to do all the pureed meals first, followed by the mechanically altered meals, and then the regular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-05 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual 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, menu review, and interview, the facility failed to ensure food was prepared to meet the needs for 3 of 3 sampled residents observed, as evidenced by the failure to provide and serve chopped meat to Resident #2 and #21, and failure to cut up meat to bite-sized pieces for Resident #5.The kitchen staff also failed to prepare ground meat on 02/02/26 as per the mechanical soft diet menu.This failure had the potential to affect 7 residents who were on physician ordered mechanical soft diets.The findings included:1) A lunch observation was made on 02/02/26 beginning at 11:49 AM in the main dining room. The posted menu for that day included a roast beef sandwich. Four residents were brought into the dining room and were accompanied by Staff I, Certified Nursing Assistant (CNA), throughout the meal. The lunch trays were served to the four residents, as noted below, and staff failed to compare the meal with the corresponding meal ticket. After the meal service on 02/02/26 at approximately 12:40 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 10 sampled residents, as evidenced by the inaccurate assessment for range of motion ability, diagnoses, and terminal illness status for Resident #7, and for range of motion ability for Resident #6.The findings included:1) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Review of the medical diagnosis included quadriplegia (partial or total loss of sensory and motor function in all four limbs and the torso). Review of current orders documented the resident was admitted to Hospice services as of 01/31/25. Review of the Hospice admission information revealed a physician signed the Certificate of Terminal Illness (CTI). This CTI was renewed with each certification period from admission to the present time. Review of the current Annual MDS dated [DATE] documented Resident #7 had no impairment to the lower extremities and had a documented diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely assess, monitor, document care, and notify the physician for a resident who exhibited cold-like symptoms for 1of 1 sampled resident, Resident #2, reviewed for change of condition. In addition, the facility failed to assess and document blood pressure prior to administering antihypertensive medication as required by the physician order for 1 of 5 sampled resident, Resident #2, reviewed during the unnecessary medication review task. The findings included: 1) Clinical record review revealed Resident #2 was re-admitted to the facility on [DATE] with diagnoses including medically complex conditions, Atrial Fibrillation, and Septicemia.The annual Minimum Data Set (MDS) assessment with a reference date of 10/29/25 documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS noted the resident reported feeling down, depressed, or hopeless, with no behavioral symptoms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy and procedure, the facility failed to ensure supervision and implementation of interventions to prevent falls for 1 of 1 sampled resident, Resident #20, which resulted in the resident sustaining 3 falls within 5 weeks.The findings included: Review of the policy titled, Fall Prevention Program dated 07/2025, documented in part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Review of the record indicated that Resident #20 was admitted to the facility on [DATE]. Medical history included Metabolic Encephalopathy (a disturbance in brain function that causes confusion), Essential Hypertension (high blood pressure), Muscle Weakness and Idiopathic Peripheral Neuropathy (nerve damage which causes pain, numbness and tingling to the lower extremities).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented 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.
- Potential for harm · D2026-02-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, observation and staff interview, the facility failed to follow the physician's order for feeding tube flush and to obtain weekly weights for 1 of 1 sampled resident, Resident #6, which was required to maintain the resident's nutritional needs and prevent complications. The findings included: 1. Review of the policy and procedure titled, Care and Treatment of Feeding Tubes dated 12/2025, documented in part, Feeding tubes will be utilized according to the physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush.A review of the record documented Resident #6 was admitted to the facility on [DATE]. Medical diagnoses included Chronic Dysphagia (difficulty swallowing). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] the resident was fed by a feeding tube. a) Review of the physician's orders documented as of 08/01/25 that Resident #6 received nutrition via a feeding tube. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the provision of foods as per resident preference for 2 of 4 sampled residents, as evidenced by the failure to ensure ice cream and mashed potatoes daily for Resident #16, and failure to ensure double portions for Resident #2.The findings included:1) Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was not done as the resident was rarely or never understood. This MDS also documented the resident was totally dependent upon staff for eating.Review of the current care plan initiated on 11/13/24 and revised on 08/26/25 documented the resident was at increased nutritional risk related to a mechanically altered diet and the need for assistance with all meals. Intervention to this care plan included to provided the diet as ordered.An observation on 02/02/26 at 12:10 PM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-08-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a clean, comfortable and homelike environment related to dirty carpet in 3 of 18 resident rooms (room [ROOM NUMBER], #9 and #14) and 1 of 24 bedside tables having 1 of 4 bolts missing from the table's surface (room [ROOM NUMBER]). The findings included: During the initial tour of the facility on 08/11/24 at approximately 9:30 AM, the following concerns were observed by the survey team: 1) room [ROOM NUMBER] was missing a large bolt from the bedside table. The carpet had multiple stains. 2) room [ROOM NUMBER] had multiple stains on the carpet. 3) room [ROOM NUMBER] had a large stain on the carpet at the end of the bed. (Photographic evidence obtained) On 08/14/24 at 10:15 AM, the Housekeeping Supervisor was asked about the carpets. She stated the facility was going to rip the carpet out, and she believed the Executive Director had received some quotes for it. She stated the carpet is made up of squares and each one can be individually removed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for 1 of 5 sampled residents, related to the medication usage of Resident #9. The findings included: Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented Resident #9 was taking an antidepressant medication during the seven-day look-back period of 05/08/24 through 05/14/24. Review of the corresponding Medication Administration Record (MAR) for the month of May 2024 lacked any provision of an antidepressant. Further review of the May 2024 MAR revealed Resident #9 received the antiplatelet medication Clopidogrel (plavix) 75 milligrams (mg) daily during that timeframe, along with the antianxiety medication Buspirone 5 mg daily. Further review of the MDS lacked the indication that the resident received these two additional categories of medications. During an interview and side-by-side record review on 08/14/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to: a) provide showers per resident schedule and/or resident choice for 3 of 3 sampled residents reviewed for Activities of Daily Living (ADL) care (Resident #122, #72, and #14); and b) provide timely nail care to 1 of 1 sampled residents reviewed for ADL's related to nail care (Resident #122) The findings included: The Activities of Daily Living Policy and Procedure, dated 06/26/22, states: 2. This [procedure] included the facility ensuring that: a. A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified below: i. Hygiene - bathing, dressing, grooming and oral care . 4. The facility will ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition , grooming, and personal and oral hygiene. 1) During observation and resident interview on 08/11/24 at 10:43…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, documented monthly pharmacy reviews, and interviews, the consultant pharmacist failed to identify the lack of behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #9). The findings included: Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the orders revealed the resident had been on the anti-anxiety medication Buspirone since 02/16/24, and the anti-psychotic medication Haloperidol since 02/05/24. Review of the record lacked any behavior monitoring for these medications. (Refer to F757 for details). The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24. Review of the monthly pharmacy recommendations from February 2024 through July 2024 lacked any recommendation related to the lack of behavior monitoring. During a phone interview on 08/14/24 at 3:05 PM, the consultant pharmacist was unable to review his records, but would check later. The consultant pharmacist was told…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure adequate monitoring of medications for 2 of 6 sampled residents. The facility failed to ensure behavior monitoring for psychotropic medication use for Resident #9, and failed to ensure appropriate antibiotic use for Resident #14. The findings included: 1) Review of the record revealed Resident #9 was admitted to the facility on [DATE], with a diagnosis of Schizophrenia. Review of the orders revealed the resident had been on the anti-psychotic medication Haloperidol since 02/05/24, and the anti-anxiety medication Buspirone since 02/16/24. The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24. Review of the current care plan initiated on 02/06/24 and revised 07/02/24 documented, I have anxious/restless behavior as evident by calling out for help loudly without a need. Resident has a history of providing false information to family and staff for attention seeking purposes. Review of the monthly Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete physician ordered laboratory services timely for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #9 and #72). The findings included: 1) Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the orders revealed the need for a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) to be drawn on 07/22/24. The record lacked any results for these labs. During an interview on 08/14/24 at 12:36 PM, the Director of Nursing (DON) was asked to locate and provide the CBC and CMP results from 07/22/24. The DON was unable to do so. The DON looked on the laboratory's website and found that four other residents had labs drawn on 07/22/24, and one on 07/23/24, but was unable to locate any for Resident #9. The DON reviewed the laboratory service binder and could not find any requisition page for 07/22/24 or 07/23/24, thus was unable to determine why the labs were not drawn as per order.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 1 sampled resident with an indwelling catheter (Resident #14). The findings included: The policy titled Enhanced Barrier Precautions and implemented 04/01/2024 documents in part: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precaution. 9. Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that places them at high risk. On 05/18/24, Resident #14 was admitted to the facility with diagnosis to include: Urinary Tract Infection, Cerebrovascular Disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-27 · tag F0880 — failed to prevent and control infections — patternProvide 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 clinical and administrative record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This is evidenced by the facility failure to follow the established protocols and policy and procedure regarding COVID outbreak testing and follow-up. The findings included: Review of the facility's policy regarding Infection Outbreak Response and Investigation, Date Implemented [DATE] and Date Reviewed/Revised [DATE] documented, Outbreak Investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all activities. c. A case definition will be developed in order to identify other staff and residents who may be affected. or ability to identify all close contacts, the facility should instead investigate the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-27 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review and staff interview, the facility failed to ensure the clinical record provided documentation or evidence that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This failure is evidenced by the review of 5 residents for immunizations history revealed that the facility failed to provide evidence of offering the pneumococcal vaccine to 3 of 5 residents reviewed (Resident #4, #11, #12) and failed to provide evidence of vaccinating 1 of the 2 remaining residents reviewed, when the resident consented to receive the pneumococcal vaccine (Resident #10). The finding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-18 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary comfortable environment and help prevent the development and transmission of communicable diseases and infections, as evidenced by the failure to ensure proper infection surveillance related to numerous Urinary Tract Infections (UTI's) in [DATE], for 3 of 4 sampled residents, affecting Residents #12, #13, and #23; failure to ensure appropriate Transmission Based Precautions for 1 of 1 sampled resident, Resident #4 who had Methicillin Resistant Staphylococcus Aureus (MRSA) of a wound; failure to ensure contact tracing with supplemental testing for the last COVID-19 positive staff identified (Staff G, cook); failure to ensure consistent monitoring of positive COVID-19 for 2 of 2 sampled residents, for Residents #12 and #14; failure to clean and disinfect the glucometer after use for 1 of 1 sampled resident, with Resident #14 by Staff D,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement and develop individualized care plans for 3 of 10 sampled residents. Specifically,related to nutrition for Resident # 1 and Resident #7, pressure ulcers for Resident #1 and Hospice Services for Resident #13. The findings included: 1) Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with a diagnosis to include Failure to Thrive, Alzheimer's Disease, Dysphagia, and Acute Kidney Disease. A review of the MDS (Minimum Data Set) 5 Day assessment dated [DATE], documented the resident's BIMS (Brief Interview Mental Status) score was 00, which means she was not able to be interviewed due to her cognition being low. Resident #1 had a significant amount of weight loss and facility acquired pressure ulcers. A review of Resident #1's revealed no care plan for weight loss and interventions for weight loss. A continued review of Resident #1's medical records for pressure ulcers reveal she is currently being treated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate care and services for 2 of 10 sampled residents. Coordination between Hospice and facility nurses related to the suprapubic catheter of Resident #13 was not maintained. Facility nurses failed to notify the physician of a hypertension (increased blood pressure) medication being held two days in a row for Resident #8. The findings included: 1) During an observation and interview on 05/16/23 at 10:06 AM, Resident #13 was lying in bed, holding onto the tubing of his suprapubic catheter (urinary draining device) and stated, Can you look at this? The area on his abdomen lacked any type of dressing, and the skin around the tubing was reddened with dried scabbing around the insertion site. Review of the record revealed Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], after hospitalization. Review of the paper record documented an order dated 04/28/23 to cleanse the suprapubic catheter site with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the provision of wound care was rendered, as per ordered, and failed to ensure coordination of care between the wound care physician and facility nurses for 1 of 1 sampled residents (Resident #1). The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE], and developed pressure wounds to the coccyx and left heel on or about 04/18/23. During a wound care observation on 05/16/23 at 12:04 PM, the wound care physician debrided the wounds, stating the wounds to the coccyx had deteriorated. The physician stated, Be sure the air mattress is functioning because the last time it deteriorated there was a problem with the specialty air mattress. Wound care notes for Resident #1 all documented the order and use of the specialty air mattress. On 05/16/23 at 12:43 PM, Staff F, Licensed Practical Nurse (LPN) and nurse who usually rounded with the wound care physician, upon gathering her supplies…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to safely store wound care medications and supplies for 2 of 2 sampled residents receiving wound care (Residents #13 and #1), and failed to ensure expired supplements and laboratory supplies were removed from 1 of 1 medication storage rooms. A random observation on [DATE] revealed the treatment cart was left unattended and unlocked. The findings included: Review of the policy Medication Storage dated [DATE] documented, Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments . 5. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed per manufacturer guidelines and standards of practice. 1) During an observation and interview on [DATE] at 11:19 AM, Staff D,…
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.
- No harm found · Ccited before2024-08-14 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an accurate and current menu was posted for residents who eat their meals at the facility. The findings included: On 08/11/24 (Sunday) at 9:00 AM, it was observed that the daily menu posted on the wall at the entrance to the dining room was labeled as being the menu for Monday. This menu documented that the lunch meal to be provided on this day was Cracker Crumb Cod, Potato Wedges, Broccoli, Roll, and Brownie, with the alternate meal being Chili with Beans and Baked Potato. During the meal observation at 08/11/24 at 12:10 PM, the main entree served to the residents was Turkey Shepherd's Pie (Ground Turkey, mashed potatoes, peas/corn/carrots), Dinner Roll, and Cheesecake. The only other meal observed being served at this time was an always available grilled cheese sandwich, tomato soup, and fresh fruit. Observation of a weekly menu posted on the bulletin board in the dining room showed the menu was for Week 1, which included the dates of 08/20/24 - 08/26/24. A search through all the weekly menus posted…
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.
- No harm found · C2023-05-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to: 1) Accurately document the number of Certified Nursing Assistants (CNAs) directly responsible for resident care and the actual hours worked by the CNA's on the 6:00 AM - 2:00 PM shift on 2 of 14 days reviewed in May 2023; and 2) Post the total number of nurses and CNA's working each shift on the Nurse Staffing Information document. The findings included: 1) The staffing schedules, including call-ins and staff postings for the past month, were reviewed with the Director of Nursing (DON) on 05/18/23 at 11:15 AM. There was a discrepancy noted between the number of CNAs on the May Schedules and the total CNA hours posted on the Nurse Staffing Information. The DON provided Daily Staffing Sheets showing the actual staff on duty during 05/01/23 and 05/15/23. There was a discrepancy in the number of CNAs on 05/04/23, 05/10/23, 05/18/23, and 05/12/23. Time sheets were requested from the Human Resource (HR) Manager to review for the actual names and hours worked by the CNAs on these dates. On 05/18/23 at approximately 12:15…
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.
- No harm found · Bcited before2023-05-18 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure documented evidence of the provision of the influenza vaccine for 4 of 5 sampled residents, was maintained in the medical record (Residents #8, #11, #12 and #14). The findings included: Review of the records revealed Resident #8 consented to receive the influenza vaccine on 10/22/22, Resident #11 consented on 10/27/22, Resident #12 consented on 10/27/22, and Resident #14 consented on 10/25/22. Further review of these records lacked any evidence of the provision of the influenza vaccine to the four residents. The Director of Nursing (DON), who was also the Infection Control Preventionist (ICP), was asked to locate and provide evidence of the provision of the influenza vaccine to the four residents. The DON/ICP provided a single list of residents in the facility who all received the influenza vaccine on 11/18/22. The DON/ICP agreed the information was not maintained in the resident's clinical records.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KPJ ENTERPRISES, LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 03/01/2022 |
| HOLLENBECK, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 03/01/2022 |
| OHAIR, JOSHUA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 03/01/2022 |
| ROCKEFELLER, KEVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 54% | since 03/01/2022 |
| WARD, GRETCHEN | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2022 |
| KR MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2022 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106097. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.