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Sea Breeze Rehab And Nursing Center

3663 15th Ave, Vero Beach, FL 32960 · For profit - Corporation · 110 certified beds · (772) 567-2552 Medicare & Medicaid certified

Call the home — (772) 567-2552 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)
  • about 22% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1460 36th St · (772) 562-7777 · Call to confirm hours
Pharmacy
Grocery
4346 28th Ct · (772) 501-7817 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1920 38th Ln · (772) 562-6440

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.2%8.7%15.4%better
Long-stay residents who lose too much weight10.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.8%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.1%2.5%3.3%worse
Long-stay residents whose ability to walk worsened7.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.4%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers13.6%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control17.9%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 table13.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine87.1%94.7%79.4%typical
Short-stay residents rehospitalized after admission29.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit8.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.952.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.401.151.80better

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

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

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

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

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

59.0% 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 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.0%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
27.8%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 27.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 72 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 0.39 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.0%CMS range 52.3–65.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.6–11.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge27.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge22.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge30.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.4%CMS range 3.0–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.261.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.42
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.17
RN hoursweekends
56.8%
Total nursing turnover
73.3%
RN turnover

How full it usually is: this home is certified for 110 beds and averages 105.1 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.22 hrs/resident/day on weekends vs 3.71 on weekdays — 13% thinner on weekends. RN hours go from 0.52 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-01-09)
6
at the previous standard inspection (2023-10-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2026-05-06 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure an informed consent for psychotropic medication(s) was obtained for residents prescribed psychotropic medications for 2 of 59 residents reviewed, who were receiving psychotropic medications, Resident #109 and Resident 25. The findings included: 1. Record review revealed Resident #109 was admitted to the facility on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Generalized Anxiety Disorder, Major Depressive Disorder, and Brief Psychotic Disorder. Review of the Minimum Data Set (MDS) assessment revealed the Brief Interview of Mental Status assessment (BIMS) dated 05/01/26 documented a score of 9, indicating moderate cognitive impairment. Review of the physician's orders for Resident #109 revealed in part the following: An order dated 04/30/26 for Lorazepam Tablet 1 MG Give 1 mg by mouth every 8 hours as needed with no end date. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-06 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to ensure resident rights were honored for 6 of 7 sampled residents as evidenced by the failure to ensure showers and/or honor shower preferences for Residents #15, #40, #38, #81, #95, and #112.The findings included:Review of the policy, Standards and Guidelines: ADL Care and Services, issued 04/20 and revised on 01/24, in part documented, Appropriate care and services will be provided for resident who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, Hygiene (Bathing/showers, dressing, grooming, nail care, oral care). Review of the facility's policy titled, ADL Care and Services, dated 04/2020 with revised date 01/2024, included the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Guideline:…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility shower schedule, record review and interview, the facility failed to honor the shower preferences and schedules for 2 of 7 sampled residents reviewed for choices, Resident #14 and #48. The findings included: 1. Review of the shower schedule revealed Resident #14 was scheduled to receive a shower on the 7 AM to 3 PM shift on Tuesdays and Fridays. A second shower schedule by room number confirmed those days and time. Review of the record revealed Resident #14 was admitted to the facility on [DATE] and moved into his current room on 07/03/24. Review of the most currently completed Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a scale of 0 to 15, indicating the resident was cognitively intact. Review of the most recently completed comprehensive assessment revealed the resident had a lower BIMS of 05, indicating cognitive confusion, but still reported the choice between a bath and a shower was somewhat…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean comfortable homelike environment for 1 of 2 units, Unit B. The findings included: Observations on 01/06/25, 01/07/25, and 01/08/25 revealed the following: a. On 01/08/at 9:30 AM: room [ROOM NUMBER]- the IV pole was rusted at base of pole. b. On 01/06/25 at 11:00 AM: room [ROOM NUMBER]A - During an interview with the resident's spouse on 01/06/25 at 11:00 AM, she stated that the chairs in the sitting room next to nurses station are disgusting. She showed surveyor the pictures of the chairs and stated this was from when he first came. She said she told someone but nothing has been done. She stated she was in the sitting room on 12/30/24 and 12/31/24, pulled up the cushion and observed trash and stained seats for 2 of the chairs in the room. The surveyor observed the spouse's concerns via observation on 01/06/25 at 2:20 PM and 01/07/25 at 7:15 AM. The couch had debris underneath the cushions as well as a paperback book that was folded…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 policy review, interview and record review, the facility failed to respond to a verbal grievance regarding missing personal items for 1 of 1 voiced grievance, affecting Resident #13. The findings included: Review of the policy, titled, Grievance-resident rights, dated 7/2024, indicated the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family member or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and/or in writing upon request including a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0641 — isolated
    Ensure 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 observation, record review, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 23 sampled residents, as evidenced by improperly coding Resident #14 as comatose, inaccurate dental status for Residents #82 and 87, and an inaccurate hearing status for Resident #87. The findings included: 1. Review of the record revealed Resident #14 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], completed for a significant change in status, documented Resident #14 was comatose. Further review of the record lacked any evidence of a comatose status. Resident #14 was interviewed on 01/06/25 at 10:18 AM, who volunteered an extensive medical history, with no mention of any comatose status. During an interview on 01/09/25 at 11:50 AM, Staff B, MDS Coordinator, was made aware of the comatose coding. The MDS Coordinator explained that section of the MDS was completed by the previous Social Service Director (SSD), who was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop and implement care plans for 2 of 23 sampled residents reviewed, Residents #87 and #15, as evidenced by lack of care plans related to hearing for Resident #87 and lack of care plans relating to self-administration of medication for Resident #15. The findings included: 1. Review of Resident #87's record revealed she was admitted to the facility on [DATE] with a diagnosis to include Wedge Compression Fracture, Rhabdomyolysis, Muscle Weakness and Abnormalities of Gait and Mobility. Review of the [Company Name] admission Nursing Evaluation dated 10/16/24 asks the question Does the resident have impaired hearing, and the answer was marked yes, no auditory aides. Review of Resident #87 care plan revealed that this resident did not have a care plan related to her hearing concerns. During observations and attempted interview with Resident #87 on 01/06/25 at 2:08 PM, the resident stated she can't hear in left ear, she is deaf and in 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 · D2025-01-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure narcotic removal was recorded in the medication administration records (MARs) for 3 of 6 sampled residents reviewed, Residents # 28, # 6 and #9. The findings included: 1. On 01/07/25 at 11:24 AM, medication storage observations were started at the B-unit. Resident # 28's medication records were selected for review. It was revealed Resident #28 had a physician order of Oxycodone HCl Oral Tablet to give 15 mg via peg-tube every 4 hours as needed for moderate-severe chronic pain. Review of the January 2025 medication and treatment administration records (MARs and TARs) were compared against the medication monitoring control record. There was a discrepancy between these records. The medication monitoring control record indicated the medication was removed twice on 01/03/25 at 10:57 AM and 3:36 PM Review of the MARs had no documentation and were not signed for the removal on 01/03/25 at 10:57 AM and administration to the resident. 2. On 01/07/25 at 12:12 PM, medication storage observation commenced at the A-unit.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to prevent elopement; failed to thoroughly investigate the incident; failed to implement corrective measures to minimize reoccurrence and failed to report the adverse event. The failure affected 1 of 2 sampled residents, Resident #1. The findings included: Review of the Facility policy, titled, Elopement and Wandering, dated 07/2024 documented: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Guideline: To provide care guidance for staff on the current standards of professional practice for residents who are identified as an elopement risk or wanderer upon clinical assessment Definition: A situation in which a incapacitated resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement (Ex: If the resident is observed by a staff member or a staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-12 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers as per residents' choice and schedule for 2 of 4 sampled residents, Residents #37 and #14. The findings included: 1. During a phone interview on 10/10/23 at 3:55 PM, the daughter of Resident #37 stated the staff were not providing her mother with showers, and their current reason was that the shower room was under construction. The daughter voiced when she requested anything, including a shower for her mother, staff constantly tell her they are understaffed and don't have time. Review of the record revealed Resident #37 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Significant Change MDS assessment dated [DATE] documented it was very important for Resident #37 to choose between a bath and a shower. Review 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2023-10-12 · tag F0641 — isolated
    Ensure 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 Minimum Data Set (MDS) assessments for 2 of 5 sampled residents, related to medication use, Residents #54 and #52. The findings included: 1. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/04/23, documented Resident #54 received insulin injections 7 of 7 days during the look-back period of 07/29/23 through 08/04/23. Review of the corresponding Medication Administration Records (MARs) for that same look-back period revealed Resident #54 only received the scheduled Lantus insulin on 08/03/23 and 08/04/23. These MARs lacked any other insulin administration. During an interview on 10/12/23 at 1:17 PM, the MDS Coordinator was asked about the Quarterly MDS dated [DATE] with the documented daily insulin injection. As the MDS Coordinator was looking up Resident #54 on the electronic medical record, she stated the resident was on daily scheduled long-acting insulin. Upon review of the August 2023 MAR, the MDS Coordinator…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure care and services for a Peripherally Inserted Central Catheter (PICC) line dressing change as ordered for 1 of 2 sampled residents with intravenous access, Resident #5. The findings included: Review of the facility's policy, titled, PICC Line or Midline Catheter Dressing Change, with a revised date of August 2023, included: Frequency - Change the dressing in the first 24 hours. After the first 24 hours, the frequency is every 7 days and PRN (as needed) if dressing is loose, damp, or soiled. Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 08/17/23. The resident's diagnoses included: Type 2 Diabetes Mellitus, Bacterial Infection, and Acquired Absence of Right Leg Below Knee. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 08/18/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to obtain a physician order for oxygen use for 1 of 3 sampled residents reviewed for respiratory issues, Resident #38; and failed to post 'oxygen in use' signage for 2 of 3 sampled residents reviewed for respiratory issues, Residents #38 and #6. The findings included: Review of the facility's policy, titled, Oxygen Administration, with a revised date of October 2010, included: the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility's policy, titled, Oxygen In Use Signage, with a revised date of 03/08/17, revealed it is the policy of the facility that wherever oxygen is in use a sign must be posted at the location. 1. Record review for Resident #38 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 blood sugar monitoring, failed to follow blood pressure parameters with medication administration, and failed to ensure consistent and appropriate monitoring of medication side effects, all as per physician orders, for 3 of 5 sampled residents, Residents #36, #46, and #54. The findings included: 1. Review of the record revealed Resident #36 was admitted to the facility on [DATE]. Review of the current physician orders documented to administer 25 milligrams of Metoprolol twice daily, withhold parameters if the systolic (upper number) blood pressure reading was less than 100, the diastolic (lower number) blood pressure reading was less than 60, or the heart rate was less than 60. Review of the September 2023 Medication Administration Record (MAR) revealed the following: On 09//19/23 at 5:00 PM, the nurse administered the Metoprolol with a documented blood pressure reading of 109/57. On 09/22/23 at 9:00 AM, the nurse administered the Metoprolol…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure accuracy of medical records related to the administration of wound care and the provision of a Central Venous Catheter dressing change, for 2 of 2 sampled residents reviewed for wound care, Residents #15 and #52, and for 1 of 2 sampled residents with intravenous access, Resident #5. The findings included: Review of the facility's policy, titled, Central Venous Catheter Dressing Changes with a revised date of April 2016, included under Section Purpose: The purpose of this procedure is to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Included under the Section Documentation: 1. The following information should be recorded in the resident's medical record: a) Date and time dressing was changed. b) Location and objective description of insertion site. c) Any complications, interventions that were done. d) Condition of sutures (if present). e) Any questions,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment for the whole facility. The findings included: During the initial tour of the facility including resident rooms on 06/13/22 and through 06/16/22 and a secondary tour completed on 06/16/22 at 9:25 AM, with Director of Operations and Regional Director of Facilities Management Region 3 the following concerns were noted, observed, and acknowledged during tour.: 1. room [ROOM NUMBER]: caulking around toilet and floors was dirty. room [ROOM NUMBER]-A: paint is peeling and shows heavy thick lines of paint roller on wall. room [ROOM NUMBER]-A:15 dead roaches were observed laying around the base of the head of bed. The floors were dirty. The privacy curtain between bed A & bed B was soiled. During the tour with Director of Operations & Regional Director, a live cockroach ran behind the bed. room [ROOM NUMBER]-B: sugar ants observed in room. The bed table chrome was rusted. The wall…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · 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, record review and interview, the facility failed to implement their smoking policy to prevent potential accidents for 5 of 5 sampled residents who smoke (Residents #29, #253, #47, #55 and #7). The findings included: On 06/14/22, the surveyor requested to see the smoking policy. The surveyor was given multiple smoking policies that documented and included the following: Tobacco-Free Environment Policy Acknowledgement documents facility is committed to providing a healthy and safe environment for our employees, Residents, and all others. Facility is a tobacco free facility. A copy of the Tobacco-Free Facility Policy is attached here to as attachment D1 (See doc). I understand and agree to enter a tobacco free Facility where I will not be allowed to use smoking or any other tobacco products as defined in the Tobacco-Free Facility In witness whereof, the parties have signed their names, symbols, or initials, on the dates indicated. Policy. Attachment D1 documents facility premises: Property…

    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 · E2022-06-16 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 15 of 25 sampled residents interviewed (Residents #1, #19, #26, #37, #44, #45, #56, #59, #80, #83, #306, #13, #64, #48 and #3). The findings included: 1. During interview on 06/13/22 at 12:07 PM, Resident #1 stated, The food is cold when it is supposed to be warm. For Breakfast, we got 1 scoop of egg and a pastry, which is not enough for breakfast. For Supper, we get a egg salad sandwich that hardly fills the bread. There is no menu. The girl said this morning, 'You have no meat. Then she went and got me some. 2. During interview on 06/13/22 at 10:42 AM, Resident #19 stated, The food is not good here, but it is better than it used to be; but it's still not good. 3. During interview on 06/13/22 at 10:12 AM, Resident #26 stated, I often eat peanut butter and jelly sandwiches because I don't like the food that is served. 4. During interview on 06/13/22 at 11:19 AM, Resident #37 stated, Saturday they served all of us a hot dog…

    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 · E2022-06-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to prepare and serve food in a safe and sanitary manner. The findings included: During the initial tour of the kitchen on 06/13/22 at 9:14 AM with Dietary Manager, the following was observed: -Staff C, Dietary Aide not wearing hairnet in kitchen. -A service contractor doing maintenance on a sink in the kitchen is bald but has facial hair not covered by a mask. -Uncooked Macaroni noodles observed on floor. Within noodles and a pile of dirt was a dead cockroach. -The floors are filthy -The griddle has a thick layer of grease and the metal piece that covers wall behind griddle has grease and is dirty. -The utensils stored in a metal container, the bottom is not clean, has black specks of a substance. -Clean metal pans are stored under toaster that has crumbs observed on edges of metal lip. -Clean dishes stored in a rollator with bottom not clean and metal sides not clean. -A piece of tile on bottom of wall is broke. Photographic evidence obtained. On 06/15/22 at 11:00 AM, with Dietary Manager, a secondary tour was conducted. It…

    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 · E2022-06-16 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for entire facility. The findings included: Review of the facility's Policy & Procedures for Pest Control, dated 05/01/11, documented, to assure the facility's buildings and grounds are maintained free of pests and to promote a safe and healthful workplace. The facility will maintain an ongoing pest control program to assure that the facility is kept free of insects, rodents and other pests. Observations made between 06/13/22 through 06/16/22 revealed the following: -Upon surveyors' entrance to the facility conference room on 06/13/22 at 8:53 AM, a live cockroach ran across the conference room table. -room [ROOM NUMBER]-A, 15 dead cockroaches observed on floor on right side of wheel by head of bed. -room [ROOM NUMBER]-B, resident stated she has sugar ants in room. -room [ROOM NUMBER]-B, dead cockroach laying on windowsill. -room [ROOM NUMBER]-B, a family…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop care plans with interventions for 3 of 23 sampled residents reviewed for care plans (Resident #25, Resident #29 and Resident #253): Resident #25 related to diagnosis of Pneumonia; and Resident #253 related to non-compliance with smoking; and Resident #29 related to smoking. The findings included: 1. On 06/06/22 Resident #25 was diagnosed with bilateral Pneumonia. An antibiotic (Amoxicillin Clavulanate Potassium 875-125 mg) was ordered to be given every 12 hours, for 10 days for the bilateral Pneumonia diagnosis. The resident's record was reviewed, and no care plan was located in the resident's record for the Pneumonia and the interventions (care he needed to receive) for the diagnosis. On 06/15/22 at 2:00 PM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. She was unable to locate in the record, a care plan for the resident's diagnosis of Pneumonia. She stated there was not one in the resident's record. 2. During an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to revise care plans for smoking for 3 of 5 sampled residents (Residents #47, #55, and #7); and failure to update care plans related to transferring device for 1 of 1 sampled resident (Resident #16). The findings included: Observations were made throughout the survey of Resident #47 and Resident #253 smoking in front of the building. 1. Review of Resident #47's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Nicotine Dependence-Cigarettes, Orthopedic Aftercare, Gangrene, Cellulitis, Type II Diabetes, Muscle Wasting, Congestive Heart Failure, Hyperlipidemia, Opioid Dependence, Depression, Peripheral Vascular Disease and Cardiomyopathy. The resident's MDS (Minimum Data Set) Medicare 5 day dated 04/26/22 documented he had a BIMS (Brief Interview for Mental Status) of 14, which indicated his cognition was intact. On 06/13/22, a review of the resident's care plan for smoking revealed it was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the nursing staff failed to ensure medications and dialysis treatment times were coordinated to promote medication regimen adherence for 1 of 1 sampled resident (Resident #56). The findings included: Clinical record review conducted revealed Resident #56 was readmitted to the facility on [DATE] with diagnosis of End Stage Renal Disease (ESRD). Review of the Minimum Data Set, significant change assessment, with reference date 05/02/22, revealed the resident was assessed as independent for skills of daily decision making; requires extensive assistance with activity of daily living and is receiving dialysis treatments. Physician's order, dated 04/07/22, documented Hemodialysis on Monday, Wednesday and Fridays, chair time is 1:00 PM and transported by facility via wheelchair with pick up time of 12 noon. Care plan, dated 04/19/22, documented the resident is at risk for complication related to receiving dialysis for diagnosis of ESRD. The interventions included observe for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0726 — failed to have competent, trained nursing staff — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure licensed nurses were able to demonstrate competency related to the provision of medication administration, ordering medications timely and performing accurate documentation. The failure affected 1 of 5 sampled residents (Resident #37). The findings included: Clinical record review conducted on 06/15/22 revealed Resident #37 was admitted to the facility on [DATE] for short term rehabilitation. Minimum Data Set, admission assessment with reference date of 04/11/22, documented the resident was assessed as independent for skills of daily decision making; requires extensive assistance with activity of daily living and received antianxiety, antidepressant, anticoagulant, antibiotic and opioid medications. Care plans initiated for the resident included: Resident is admitted for short-term placement, Resident would like to complete therapy, get stronger and go home, dated 04/05/22. The plan documented interventions as administer medications per…

    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 · D2022-06-16 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, the facility failed to ensure garbage and refuse were disposed of properly. The findings included: During a kitchen tour on 06/13/22 at 9:14 AM, with the Dietary Manager, it was observed around the outside of the dumpster scattered on the grass, the following items: plastic utensils, cardboard boxes, used gloves and other pieces of garbage that couldn not be identified. The Dietary Manager acknowledged this finding during the tour. Photographic evidence obtained.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASTON HEALTH — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 3 of 54.1-1.1 vs chain
The other 37 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Crescent Health And Rehabilitation CenterSarasota, FL 1 of 5Kensington Gardens Rehab And Nursing CenterClearwater, FL 1 of 5Nursing & Rehabilitation Center Of New Port RicheyNew Port Richey, FL 1 of 5Oak Haven Rehab And Nursing CenterAuburndale, FL 1 of 5Vero Beach Care CenterVero Beach, FL 2 of 5Baya Pointe Nursing And Rehabilitation CenterLake City, FL 2 of 5Capri Health And Rehabilitation CenterVenice, FL 2 of 5Creekside Health And Rehabilitation CenterSarasota, FL 2 of 5Fairway Oaks CenterTampa, FL 2 of 5Flagler Health And Rehabilitation CenterBunnell, FL 2 of 5Haines City Rehabilitation And Nursing CenterHaines City, FL 2 of 5Highlands Lake CenterLakeland, FL 2 of 5Indian River CenterWest Melbourne, FL 2 of 5North Port Rehabilitation And Nursing CenterNorth Port, FL 2 of 5Pensacola Nursing & Rehabilitation CenterPensacola, FL 2 of 5Riverwood CenterJacksonville, FL 2 of 5Sandgate Gardens Rehab And Nursing CenterFort Pierce, FL 2 of 5Tierra Pines CenterLargo, FL 2 of 5Viera Del Mar Health And Rehabilitation CenterViera, FL 2 of 5Winter Garden Rehabilitation And Nursing CenterWinter Garden, FL 3 of 5Cedarbrook Health And Rehabilitation CenterFort Myers, FL 3 of 5Coquina CenterOrmond Beach, FL 3 of 5Eagleridge Health And Rehabilitation CenterFort Myers, FL 3 of 5Fouraker Hills Rehab And Nursing CenterJacksonville, FL 3 of 5Hillside Health And Rehabilitation CenterZephyrhills, FL 3 of 5Oakpark Health And Rehabilitation CenterPalm Harbor, FL 4 of 5Bridgeview CenterOrmond Beach, FL 4 of 5Coastal Health And Rehabilitation CenterDaytona Beach, FL 4 of 5Debary Health And Rehabilitation CenterDebary, FL 4 of 5Fernandina Beach Rehabilitation And Nursing CenterFernandina Beach, FL 4 of 5Island Lake CenterLongwood, FL 4 of 5Meadowpark Health And Rehabilitation CenterDunedin, FL 4 of 5Parkside Health And Rehabilitation CenterDeland, FL 4 of 5Ruleme CenterEustis, FL 4 of 5Seaside Health And Rehabilitation CenterDaytona Beach, FL 5 of 5Bayview CenterEustis, FL 5 of 5Osprey Point Nursing CenterBushnell, FL

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

Who owns this facility

Owner / managerTypeRoleShareSince
AC CARE HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/07/2018
CITADEL CARE GROUP LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 05/07/2018
GUTMAN, SAMUELIndividualINDIRECT OWNERSHIP INTERESTsince 05/07/2018
JOSEPH-SAINT FLEUR, LINAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/05/2023
WILDES, DONNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
BALLOUT, HUSSIENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2025
CANCELLI, COLEENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/02/2024
RAYNER, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/22/2025
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$12.4M
Net patient revenuemost recent cost report
-3.0%
Operating marginrevenue minus expenses
$2.9M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 16%Other / private 33%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$357per resident / day
operating cost
$10,851per month
≈ monthly operating cost
$347per day
avg. revenue, all payers

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

What families pay in FL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105399. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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