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Vivo Healthcare Wauchula

401 Orange Place, Wauchula, FL 33873 · For profit - Corporation · 79 certified beds · (863) 773-3231 Medicare & Medicaid certified

Call the home — (863) 773-3231 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
515 Carlton St · (863) 773-6606 · Call to confirm hours
Pharmacy
301 S 6th Ave · (863) 767-1195 · Call to confirm hours
Grocery
204 E Palmetto St · (863) 448-2984 · Call to confirm hours
Park
209 W Main St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 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 held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.3%8.7%15.4%better
Long-stay residents who lose too much weight3.0%5.5%5.4%better
Long-stay residents with a catheter left in their bladder2.0%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.0%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.5%4.6%6.5%typical
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 injury1.4%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.6%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.0%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control13.7%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table6.3%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.6%94.7%79.4%better
Short-stay residents rehospitalized after admission26.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit13.8%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.502.131.67better
Long-stay outpatient ER visits per 1,000 resident days2.211.151.80worse

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

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

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

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

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

46.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.6%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
59.6%U.S. median 56.6%
Met the expected recovery
0.54U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.30hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 59.6% 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 57 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.6%CMS range 34.6–57.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.2–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.6%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 discharge49.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.3%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 hospitalization7.8%CMS range 4.9–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.331.02Oct 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

0.43
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.42
Total nurse hours/ resident / day
0.26
RN hoursweekends
34.4%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 79 beds and averages 69.8 residents a day — about 88% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.26 hrs/resident/day on weekends vs 3.49 on weekdays — 7% thinner on weekends. RN hours go from 0.49 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

12
deficiencies at the latest standard inspection (2024-06-27)
5
at the previous standard inspection (2022-11-15)

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.

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2024-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food, in accordance with professional standards for food service safety. The findings included: 1) During the initial kitchen/food service observation tour conducted on 06/24/24 at 9 AM and accompanied with the facility's Certified Dietary Manager (CDM), the following were noted: a) The entire surface of the storeroom floor (10' X 20') was noted to be in disrepair with large areas of the concrete broken, rust, and peeling paint. It was discussed with the CDM that there were areas of standing water in pockets of the missing concrete surface which house bacteria that staff transfer into the main kitchen area. Also peeling paint is also transferred in the kitchen area. b) The exterior door and entry area to the walk-in refrigerator was noted to be rust laden and build-up of a black mold type matter. It was discussed with the CDM that the entry door and door area are not cleaned properly on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents were treated in a dignified manner when entering the resident's room and during medication administration for 2 of 5 residents observed for medication pass administration (Residents #38 and #165). The findings included: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity dated 09/01/23 included in part the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain dignity and respect resident rights. 12. Maintain resident privacy. Review of the facility's policy titled, Medication Administration with a revised date of 09/01/23 included in part…

    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 · D2024-06-27 · 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 observations, interviews and record review, the facility failed to assess the safety of smoking for 1 of 1 resident reviewed for smoking (Resident #37). The findings included: A review of the facility's policy titled, Resident Smoking, dated 09/01/23, revealed the following: The facility provides a safer and healthier environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further evaluated using the Resident Smoking Safety Screen to determine whether supervision is required for smoking or if the resident is safe to smoke at all. In an interview conducted on 06/24/24 at 11:00 AM, Resident #37 stated that he smokes about 1-3 cigarettes a day. The facility has its own smoking schedule, and smoking is in the back patio near the dining room. When asked about the smoking supplies, Resident #37 reported that they were located in the nurse's station in a locked box. A record review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to obtain orders for catheter care for a resident admitted with an indwelling Foley catheter for 1 of 1 resident sampled for urinary catheter (Resident #31). The findings included: Record review for Resident #31 revealed the resident was admitted to facility on 02/04/22 with the most recent readmission on [DATE] that included diagnoses of Urinary Tract Infection and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set for Resident #31 dated 04/22/24 revealed in Section C Brief Interview of Mental Status (BIMS) score of 15, which indicated a cognitive response. Review of the Admission/readmission Nursing Evaluation for Resident #31 dated 06/21/24 documented under Section K Urinary: Does the resident have a catheter? Was answered yes. Catheter type/size? Was answered 16Fr. Reason for catheter - Neuromuscular dysfunction of the bladder. Review of Medication Administration Record (MAR) for Resident #31 from 06/21/24 to 06/24/24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to monitor nutritional status in a timely manner for one of one residents reviewed for Dialysis (Resident #22). The findings included: The facility's policy titled, Nutritional Management, dated 09/1/2023 revealed the following: A systematic approach is used to optimize each resident's nutritional status: Identifying and assessing each resident's nutritional status and risk factors. Evaluating/analyzing the assessment information. Developing and consistently implementing pertinent approaches. Monitoring the effectiveness of interventions and revising them as necessary. A record review revealed Resident #22 was readmitted on [DATE] with diagnoses of End-Stage Renal Failure, Type 2 Diabetes, and dependency on Dialysis. The Quarterly Minimum Data Set, dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired. The Physician orders revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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 observations, interviews, and record review, the facility failed to follow tube feeding as per the Physician ' s orders for 1 of 1 resident review for tube feeding (Resident #21). The findings included: Resident #21 was admitted on [DATE] with a diagnosis of traumatic brain injury and gastroesophageal reflux disease. A review of the Physician ' s orders revealed an order for tube feeding Jevity 1.5 (tube feeding formula) starting at 10:00 AM to run for 50 milliliters (ml) an hour for 20 hours and to turn the tube feeding off at 6:00 AM. In an observation conducted on 06/24/24 at 10:05 AM, Resident #21 was noted in bed with the tube feeding running at 50 ml an hour. The tube feeding bag was noted to have Jevity 1.5 (tube feeding formulary), which started on 06/24/24 at 10:00 AM and was at the 1000 ml level in a 1000 ml capacity bottle. In an observation conducted on 06/24/24 at 2:05 PM (about four hours later), Resident #21 was noted with the tube feeding running at 50 ml an hour. The same tube feeding…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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 provide tracheostomy care in accordance with professional standards of practice and failed to implement appropriate interventions for tracheostomy care for 1 of 1 resident sampled for respiratory care (Resident #21). The findings included: Review of the facility's policy titled, Tracheostomy Care dated 09/01/23 included in part the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 3. Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan such as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility attending physician failed to document on irregularities identified with recommendations by the consulting pharmacist for 1 of 5 residents sampled for Unnecessary Medications (Resident #2). The findings included: Review of the facility's policy titled, Medication Regimen Review dated 08/07/22 included in part the following: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Policy Explanation and Compliance Guidelines: 6. d) Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Record review for Resident #2 revealed the resident was admitted to facility 01/10/23, the resident went out of the facility on 03/10/24 and was readmitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Right Femur, Major Depressive Disorder, and Generalized Anxiety…

    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 · D2024-06-27 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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, interview, and record review it was determined that the facility failed to prepare food in a form designed to meet the individual needs of 5 (Residents #23, #24, #26, #36, and #41) of 5 sampled residents with physician ordered pureed diet. The findings included: *Review of the facility's policy for Pureed Food Preparation noted a Date Implemented of 09/01/23 and Reviewed by Clinical Services. Further review of the Policy Explanation and Compliance Guidelines noted: (2) Pureed foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. (3) If the food item requires chewing, it will be excluded from the pureed diet. References: Center for Medicare & Medicaid Services, State Operation Manual (SOM), Appendix PP Guidance to Surveyors for Long Term care Facilities (November 2017 Revision) 1) During the observation of the lunch meal in the main kitchen on 06/24/24 at 11:15 AM, and accompanied with the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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, it was determined that the facility failed to follow physician ordered fluid restriction diet for 2 ( Residents #214, and #22) of 2 sampled residents. The findings included: *Review of facility's policy for Fluid Restriction on 06/24/24 noted the following: Policy : It is the policy of the facility to ensure that fluid restrictions will be followed in accordance with physician's orders. Policy Explanation: Fluid restrictions are basically the restriction of fluid intake. This may be due to underlying medical conditions that may cause fluid build-up such as Congestive Heart Failure (CHF), or End Stage Renal Disease (ESRD), in addition to electrolyte disorders such as hyponatremia. Fluid restriction can vary according to the resident's condition and the physician judgement. Compliance Guidelines: (1) The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-06-27 · 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 interviews and record review, the facility failed to accurately document code status for 1 of 29 sampled residents (Resident #50). The findings included: Record review for Resident #50 revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Generalized Anxiety Disorder, Major Depressive Disorder, and Aphasia Following Cerebral Infarction. Review of the Minimum Data Set for Resident #50 dated 04/22/24 documented in Section C, a Brief Interview of Mental status score of 0, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #50 revealed an order dated 6/21/24 for Code Status: Full Code Review of the Social Services Progress note for Resident #50 dated 09/10/23 documented the following: Confirmed with Proxy that resident is a DNRO code status. Review of the Care Plan for Resident #50 dated 08/10/23 with 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to practice hand hygiene while donning and doffing gloves during med administration observation for 2 of 5 residents reviewed for medication pass (Residents #165 and #38), and during tracheostomy care for 1 out of 1 resident reviewed for respiratory care (Resident #38). The findings included: Review of the facility's policy titled, Hand Hygiene dated 09/01/23 included in part the following: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-15 · 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, record reviews, and interviews, the facility failed 1) to maintain the ceiling in a safe and sanitary manner in one of one kitchen observed and, 2) failed to store food in accordance with professional standards, related to storing opened food without a date, in the kitchen and in one of two nourishment refrigerators. Findings included: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 11/07/22 at 10:30 a.m. A hole was observed in the ceiling near the dish washing area with exposed wires. The CDM stated that's where they removed the ceiling fan from. An opened bag of grits was observed next to the stove without an opened date. This was confirmed by the CDM, and she immediately labeled the opened bag of grits. The refrigerator in the nourishment room on the east wing was observed to contained an opened gallon of ice cream undated and an opened bag of chicken nuggets without an opened date. The CDM immediately discarded the items. She reported the nursing staff were responsible for labeling and dating foods 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-15 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) The following observations were made of staff members wearing surgical masks inappropriately: - On 1/31/23 at 11:09 a.m., identified Staff D, Housekeeper, standing in the entrance to room [ROOM NUMBER] with a surgical mask below the chin. - On 1/31/23 at 11:42 a.m., observed Staff I, Personal Care Assistant (PCA) enter the kitchen from the dining room wearing surgical mask below the nose. The staff member left the kitchen and returned a moment later continuing to wear surgical mask below the nose. - Staff H, Hospice Certified Nursing Assistant (CNA) was observed, on 1/31/23 at 12:05 p.m., standing in the middle hallway of the East wing. The staff member was wearing a surgical mask below the chin as she looked into the units shower room. A few moments later Staff H was observed at the end of the north hallway speaking with a resident with the surgical mask below the nose and propelled the resident from that area toward the nursing station with the mask below the chin. - On 1/31/23 at 12:07 p.m., Staff F, CNA,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident centered care plan was developed and implemented related to two anti-depressant medications, for one resident (#55) of five residents sampled for unnecessary medications. Findings included: On 11/08/2022 at 3:39 p.m., Resident #55 was observed to be sleeping in bed with the television on. A second observation was conducted on 11/08/2022 at 4:44 p.m. of Resident #55 lying in bed watching television, smiling at the television screen, and dressed appropriately for the time of day. A medical record review for Resident #55 indicated she was originally admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses including: End Stage Renal Disease (ESRD), renal dialysis, major depressive disorder, and insomnia. A review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, Resident #55 had a Brief Interview for Mental Status (BIMS) score was 10, indicating moderate cognitive impairment. A review…

    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 · D2022-11-15 · 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 reviews, the facility failed to 1)provide care and services in accordance with physician's orders and the plan of care for one resident (#271) of three residents sampled for nutrition services and, 2) failed to document an alteration in skin integrity for one resident (#32) of one resident sampled for skin impairments. Findings included: 1) A review of Resident #271's medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, encounter for attention to gastrostomy, and sepsis. A review of Resident #271's physician's orders revealed a dietary order, dated 10/20/2022, for a Nothing by Mouth (NPO) diet. A review of Resident #271's care plan revealed a problem, dated 10/21/2022, that Resident #271 was NPO and relied on tube feedings to meet 100% of estimated nutritional needs. A review of Resident #271's Progress Notes revealed a note, dated 10/25/2022 at 5:35 PM, documented by Staff G, Registered Nurse (RN) that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 monitor behaviors and side effects for psychotropic medications for one resident (#63) out of five residents sampled for unnecessary medications. Findings included: A review of the admission Record for Resident #63 revealed he was initially admitted into the facility on [DATE] with diagnoses that included major depressive disorders and unspecified dementia. Section C: Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was rarely/never understood. Section N: Medications of the MDS indicated he received antipsychotics and antidepressants for seven days. A review of the Order Summary Report with active orders as of 09/01/22 to 11/01/22 revealed the following orders: Donepezil HCL Tablet 10 milligrams (MG)- Give 1 tablet by mouth at bedtime related to down syndrome, unspecified dementia without behavioral disturbance Mirtazapine Tablet 7.5 MG- Give 1 tablet by mouth at bedtime related to major depressive disorder…

    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 · E2021-03-26 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to provide an activity program based on the assessment and care planned preferences for three (#40, #7, and #42) of three residents reviewed for activities out of a total sample of 29 residents. Findings included: 1. Review of Resident #40's admission record revealed an original admission date in 2016. Review of the annual Minimum Data Set (MDS) assessment, dated 2/4/21, revealed that the resident was rarely/never understood therefore the Brief Interview for Mental Status (BIMS) was not conducted. Continued review of the MDS revealed the resident had short and long term memory impairment and was unable to participate in the activity preference interview. The staff assessment of activity preferences was completed and listed that the resident had no activity preferences check marked. A review of the prior MDS annual assessment conducted 3/12/20 revealed the resident interview for activity preferences was conducted. This indicated that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 ensure respiratory equipment was maintained in a sanitary manner for 2 (#1 and #15) of 2 residents. Findings included: Review of the medical record for Resident #1showed a readmission date of 01/20/21, with an initial admission date of 09/17/20. As per the admission face sheet, diagnoses included: morbid (severe) obesity, and chronic obstructive airway disease. The minimum data set (MDS) dated [DATE], section C - cognitive patterns, revealed a brief interview for mental status (BIMS) of 15, indicating intact cognitive status; Section G - Functional status indicated resident required extensive assistance with two plus person assist for activities of daily living (ADL's) including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Continued review of the Physician's Orders revealed Oxygen at 2 Liters PRN (as needed) for saturation below 90%, use every 24 hours as needed for shortness of breath, and 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 · Ecited before2021-03-26 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Record review showed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified anxiety disorder, unspecified single episode major depressive disorder, unspecified mood (affective) disorder, and unspecified dementia without behavioral disturbance. The Order Summary Report (OSR) for active physician orders as of 3/26/21 indicated the following psychotropic medications: - Buspirone HCl 5 mg - give one tablet by mouth four times a day for anxiety. Order start date: 2/8/21. - Depakote Delayed Release 250 mg - give one tablet by mouth two times a day for mood disorder. Order start date: 3/14/21. - Melatonin 3 mg tablet - Give one tablet by mouth at bedtime for insomnia. Order start date: 3/9/21. - Risperdal 0.5 mg tablet - Give one tablet by mouth in the morning for Bipolar disorder. Order start date: 3/10/21. Additionally, the OSR instructed staff to: - Behavior Monitoring - Anti-anxiety Behavior Code: 0= none, 1= Restlessness, 2= pacing, 3= Continuous…

    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 · D2021-03-26 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 that it provided accurate written beneficiary notifications to residents that were being discharged from Medicare Skilled Services for two (#10 and #13) of three residents reviewed for Beneficiary Protection Notices. Findings included: 1. Record review revealed Resident #10 was recently re-admitted to the facility on [DATE]. The resident's admission Record identified Resident #10 was his own responsible party. The facility delivered a Notice of Medicare Non-Coverage, CMS form 10123-NOMNC, to the resident which indicated his coverage for Skilled Nursing/Therapy would end on 1/12/2021. The resident also received a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), CMS form 10055, which indicated that beginning on 1/13/2021 the resident may have to pay out of pocket for care if there was not other insurance that may cover these costs. The notice identified the reason Medicare may not pay was because the resident had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-26 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and five errors were identified for four (#47, #40, #61, and #20) of six residents observed. These errors constituted a 17.24% medication error rate. Findings included: 1. On 3/24/21 at 10:19 a.m., an observation was made with Staff Member H, Licensed Practical Nurse (LPN) of medication administration to Resident #47. The staff member obtained a blood glucose level of 210 from the resident. She returned to the medication cart and removed a Novolog Flexpen that was prescribed to Resident #47. The LPN attached a safety needle to the Flexpen and rotated the dose selector to 2, indicating that 2 units of insulin would be administered. The staff member injected the two units of Novolog insulin into the resident. At 10:27 a.m. on 3/24/21, Staff H was asked if she primed Flexpens, she stated, you mean to see if they work, no. The staff member confirmed she did not prime the Flexpen prior to…

    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 · D2021-03-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    Based on observations, record reviews, and interviews the facility failed to ensure one (West) out of two treatment carts were locked and inaccessible to visitors and residents when unattended, and one (North) out of three medication carts observed did not contain expired medication and insulin was refrigerated prior to opening. Findings included: On 3/25/21 at 5:14 p.m., an observation was made of an unlocked treatment cart on the [NAME] hall. The treatment cart was inside the nursing station; however the station did not provide barriers to visitors and/or residents from entering. The drawers of the treatment cart contained topical medicated lotions, creams, and gels. Staff Member I, Licensed Practical Nurse (LPN), confirmed the treatment cart was unlocked while she was elsewhere on the unit. At 2:01 p.m. on 3/26/21, the Director of Nursing (DON) stated she was aware of the situation regarding the unlocked treatment cart. She stated that medication/treatment carts should be locked when unattended and confirmed the nursing station on the [NAME] hall was accessible to visitors 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.

    Pharmacy Service 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 VIVO HEALTHCARE — 12 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 52.4-0.4 vs chain
Health inspection 2 of 51.9+0.1 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 11 homes this chain runs (chain average 2.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ST AMARO HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2023
JEK HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
JEK IRRV TR IIOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
NMJ HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
KAGAN, JEFFREYIndividualDIRECT OWNERSHIP INTERESTsince 09/01/2023
NMJ IRRV TR IIOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 09/01/2023
GLUCK, BENJAMINIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL12%since 09/01/2023
CUKIER, JOSEFIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
FRIEDLAND, SHALOMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
BECKER, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/10/2025
JAKOBOVITS, NATHANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/10/2025
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 09/01/2023
PEASE BELL CPAS LLCOrganizationADP OF THE SNFsince 09/01/2023
SUMMATION FINANCIAL SERVICES LLCOrganizationADP OF THE SNFsince 09/01/2023
VIVO HEALTHCARE CONSULTING LLCOrganizationADP OF THE SNFsince 09/01/2023
GELDART, DONALDIndividualADP OF THE SNFsince 09/01/2023
MESSIER, AMYIndividualADP OF THE SNFsince 09/01/2023

CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.7M
Net patient revenuemost recent cost report
-15.1%
Operating marginrevenue minus expenses
$97K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 9%Other / private 36%

This home reported $97K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$347per resident / day
operating cost
$10,538per month
≈ monthly operating cost
$301per 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 105362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-27, 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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