Luxe At Wellington Rehabilitation Center The
10330 Nuvista Avenue, Wellington, FL 33414 · For profit - Corporation · 120 certified beds · (561) 795-3360 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $58,835 in federal fines (most recent 2025-04-16)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
- about 18% of its spending goes to commonly-owned related companies
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.1% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.0% | 14.4% | 18.9% | better |
| Long-stay residents with pressure ulcers | 13.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.7% | 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 table | 11.1% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.6% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.9% | 9.1% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.4% 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 747 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 243 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 0.81 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.4%CMS range 57.8–64.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.3%CMS range 10.8–15.3 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 49.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.5%CMS range 6.1–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 100.5 residents a day — about 84% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.53 hrs/resident/day on weekends vs 3.98 on weekdays — 11% thinner on weekends. RN hours go from 0.97 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above 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
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2025-04-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policy review; the facility failed to protect a resident's right to be free from neglect by failure of staff to respond timely to the resident's change of condition which resulted in hospitalization for 1 of 2 residents sampled for change in condition (Resident #4). The findings included: The facility's policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin issued 08/2022 and revised 01/2024 revealed, Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident (s) requires but a facility fails to provide them, to the resident (s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Resident #4 was admitted to the facility on [DATE] post-acute care hospitalization. Diagnoses included Dysarthria following Cerebral Infarction, Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Asthma, Heart Failure…
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.
- Actual harm · Gcited before2025-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards by failing to recognize one out of 2 residents sampled (Resident #5), after admission to the nursing home was not on medication for a diagnosis of Atrial Fibrillation. The resident was readmitted to the hospital with a diagnosis of Bilateral Pulmonary Embolism. The findings included: Resident #5 was admitted to the facility post-acute care hospitalization on 03/07/25. Her admitting diagnoses included Staphylococcal Arthritis of Left Knee, Cellulitis of Left Lower Limb and Unspecified Atrial Fibrillation. Her Brief Interview for Mental Status was 15 on the 5-day Minimum Data Set with an assessment reference date of 03/12/25. This revealed the resident had intact cognition. A review of the Electronic Health Record (EHR) revealed the resident was evaluated by a nurse practitioner (NP) on 03/07/25. The NP note revealed was found with new onset of afib/aflutter- started…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate and timely care and services for 3 of 24 sampled residents as evidenced by the failure to coordinate care with a consultant physician to ensure continued administration of antibiotics for Resident #4; failure to ensure care for a skin tear to the left lower extremity of Resident #116; and failure to ensure documented blood pressure readings at the time of administration of an antihypertensive (blood pressure) medication with physician ordered parameters for Resident #116; and failure to follow physician ordered parameters for antihypertensive medications for Resident #127.The findings included:1) Review of the record revealed Resident #4 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure standards of practice for administration of medication for 1 of 3 sampled residents, as evidenced by failure to ensure Resident #4 received medication as prescribed and ensure medications are refilled in a timely manner. The findings included:Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of medical diagnosis documented a history of cerebral infarction with hemiparesis (stroke with paralysis on one side).During an observation of medication administration on 12/08/25 at 9:56 AM Staff A, Licensed Practical Nurse prepared Eldertonic (appetite supplement) 15milliliters (ml), Levetiracetam (seizure) 500mg (1 tablet) Pantopazole (acid reflux) 40 mg (1 tablet), and Lactulose (increase ammonia level) 15grams/15ml (30ml). After pouring 30 milliliters of Lactulose in a medicine cup, Staff A handed the surveyor the medicine bottle and stated He is out of this medication. It had to be reordered. Observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation and interviews, the facility failed to provide residents with a dignified existence and communication with staff in and outside of the facility for 3 of 4 sampled residents reviewed for resident rights (Resident #6, #7 and #8). The findings included: 1). In an observation conducted on 04/16/2025 at 2:00 PM on the second floor of the facility, the surveyor noted that the nurses' station was empty. The surveyor walked around for 45 minutes and never saw a staff member. There were 40 residents on this second floor unit. 2). In an interview conducted on 04/16/2025 at 2:35 PM Resident #6's wife stated that she can never get in contact with the facility staff when she calls, she always must come to the facility if she has a question which is never answered because it seems that no one ever has an answer. Resident # 6's wife further stated that she doesn't see nurses nor CNA's (certified nursing assistants) around during her visits. Record review revealed Resident #6 was admitted on [DATE] post CVA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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, record review, and interview, the facility failed to ensure proper indwelling urinary catheter care and services for 1 of 3 sampled residents, as evidenced by the failure to assess for and or attempt to discontinue the indwelling urinary catheter for Resident #1. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE], after hospitalization for back surgery. Review of the hospital record revealed the indwelling urinary catheter was placed at the time of the surgery. The hospital discharge instructions lacked any documentation related to the indwelling urinary catheter. The hospital record lacked any documented attempt at removal of the device. Review of the transfer form dated 09/04/24 from the hospital documented Resident #1 had a Foley catheter (indwelling urinary catheter) in place but lacked any indication for use and lacked information as to if the hospital made an attempt to remove the device. Review of the admission Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 policy review, observation, record review, and interview, the facility failed to ensure proper care and services for the intravenous line for 1 of 1 sampled resident, as evidenced by the lack of dressing changes as per order for Resident #2. The findings included: Review of the policy Central Lines revised 05/2024 documented, in part, Procedure: . 2. Ensure infection control standards are maintained during the care of the central line including but not limited to: a. Change dressing routinely and per physician orders. Review of the policy Documentation revised 01/2024 documented, in part, Procedure: . 4. documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the orders revealed the resident had had several peripheral IVs (intravenous access devices) placed throughout his stay at the facility, with the most recent being a midline (specific type of central…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview, the facility staff failed to provide necessary care and services to ensure adequate monitoring for 2 of 3 sampled residents (Resident #1 and #2) who experienced significant changes in condition requiring hospitalization; and the facility failed to assess skin changes for 1 of 3 sampled residents (Resident #3) after skin impairments were identified and treated to ensure resolution. The findings included: 1) Clinical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] after a short hospitalization due to Hematuria. Review of the Minimum Data Set, admission assessment with reference date of [DATE], documented the resident was assessed as independent for skills of daily decision making, has an indwelling urinary catheter and was receiving anticoagulant, antibiotic and hypoglycemia medications. The resident did not receive oxygen therapy. Review of Care Plans revised on [DATE], documented the following: The resident is at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
Based on observation, interview and record review, the facility failed to implement care practices to prevent excessive tension on the indwelling urinary catheter to minimize complications. The failure affected 1 of 1 sampled resident (Resident #6). The findings included: Review of CDC recommendations for catheter care include the following: Properly secure catheters to prevent movement and urethral traction, maintain a sterile closed drainage system, maintain good hygiene at the catheter urethral interface, maintain unobstructed urine flow and maintain drainage bag below level of bladder at all times. Observation of catheter and wound care for Resident #6 was conducted on 10/29/24 at 9:38 AM. Staff D, a Certified Nursing Assistant, the Wound Care Nurse and the Unit Manager assisted with the provision of care. Staff D and the Wound Care Nurse prepared their supplies, performed hand hygiene and donned proper personal protective equipment. Staff D started the provision of care with the Wound Care Nurse by opening the resident's brief and turning the resident to place a pad underneath.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review and interview, it was determined, the facility failed to ensure licensed nurses were able to demonstrate competency related to the provision of medication administration and following physician's orders. This failure affected 2 of 3 sampled residents (Resident #2 and #3). The findings included: 1) Clinical record review revealed Resident #3 was admitted to the facility for rehabilitation services with multiple diagnoses including Heart Failure and Hypertension on 10/07/24. Review of Physician's orders dated 10/08/24, documented Amlodipine Besylate 5 milligrams give 1 tablet by mouth two times a day, scheduled at 9 AM and 9 PM and Carvedilol Tablet 6.25 milligrams, give 1 tablet by mouth every 12 hours for Hypertension, scheduled at 9 AM and 5 PM. The medications have prescribed parameters, hold for systolic blood pressure less than 110 or heart rate less than 60. Review of the Medication Administration Record dated 10/2024, documented Resident #3 received the prescribed medications identified above with no evidence of blood pressure monitoring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-27 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure sufficient staffing as evidenced by failure to provide timely administration of medications for 1 of 6 sampled residents (Resident #50 .refer to F684); ineffective communication for 2 of 2 sampled residents (Residents #29 and 394 (refer to F676); and numerous resident / family complaints from 13 of 31 sampled residents / representatives (Residents #394, #393, #192, #39, #66, #33, #4, #29, #193, #63, #1, #194, and #395). The findings included: 1) On 09/24/24 at 11:49 AM, Resident #50's family member was interviewed via telephone and stated that he felt [Resident #50] had declined due to not participating in therapy as much as she needed to because she was not being provided her medications in a timely manner. When she doesn't get her medications on time, it can affect her blood pressure, she becomes dizzy, and she doesn't want to get out of bed to attend therapy. A review of Resident #50's medication orders showed active orders 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.
- Potential for harm · Dcited before2024-09-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 interview and record review, the facility failed to ensure 3 of 3 sampled residents were spoken to and cared for in a dignified manner (Residents #18, #39, and #33). The findings included: 1) Review of the record revealed Resident #18 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current orders revealed the resident had an admission order dated 08/30/24 for the use of barrier cream, a protective cream, every shift and as needed. A secondary order was written on 09/01/24 to clean the buttock with normal saline and apply zinc oxide every shift. This order was typically used when a resident has excoriation to the buttock. During an interview on 09/24/24 at 10:33 AM, when asked if she was treated with dignity and respect, Resident #18 stated with some of the staff it's like they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-09-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure adequate staff communication with 2 of 2 sampled residents who were unable to speak English (Resident #29 and #394). The findings included: 1) A review of the Electronic Health Record documented Resident #29 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Need for Assistance with Personal Care, and Difficulty in Walking, A review of the 5 day Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #29 has a BIMS (Brief Interview for Mental Status) score of 7 out of 15 (cognitively impaired). It also documented in Section A of the MDS that the resident is of Hispanic origin and her preferred language is Spanish. It also documents her desire to have an interpreter to communicate with a doctor or health care staff. On 09/23/24 at 11:01 AM, an attempt was made to interview Resident #29, but she was unable to understand English. Her [family member] who was in the room at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure timely administration of two prescribed medications for 1 of 6 sampled residents reviewed for medications (Resident #50). The findings included: Record review revealed that Resident #50 was admitted on [DATE] with diagnoses which included Parkinson's Disease, Syncope and Collapse, Orthostatic Hypotension, and Hypertension. A review of Resident's 5-day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 15 out of 15 (cognitively intact). On 09/24/24 at 9:45 AM, during an interview with Resident #50, she stated that she has run out of her medications a couple of times for 1-2 days. She stated she didn't want to speak about it further but provided the surveyor with her samily members number and asked that he be interviewed for further details. On 09/24/24 at 11:49 AM, Resident #50's family member was interviewed via telephone and stated that he felt Resident #50 had declined due to not participating in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-27 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure beverage of choice and timeliness of meals, as per preference for 3 of 4 sampled residents (Residents #18, #31, and #143). The findings included: Review of the Meal Service of Operation schedule revealed breakfast for Wing #3 on the second floor was scheduled for delivery between 8:15 AM and 8:30 AM daily. Residents #18, #31, and #143 resided on this unit. 1) Review of the record revealed Resident #18 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current orders revealed Resident #18 was on a regular textured and thin liquid consistency diet. During an interview on 09/23/24 at 12:49 PM, Resident #18 reported that breakfast was consistently late, being served to her between 9 AM and 10:30 AM, and that she could not get any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-02 · tag F0582 — isolatedGive 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 review and interview, the facility failed to issue refunds due to 1 of 1 sampled resident (Resident #1) representative within 30 days of the Resident's death. The findings included: Review of Resident #1's clinical record on [DATE] documented Resident #1 was admitted to the facility on [DATE]. Her admitting diagnoses included Coronary Artery Disease, Anxiety Disorder, and hypertension. The Clinical record also revealed that Resident #1 was admitted to the facility for skilled rehabilitation services which included physical therapy, occupational therapy, and respiratory therapy. In an interview conducted with Resident #1's Representative on [DATE] at 9:17 AM, he reported that Resident #1's skilled services ended [DATE], as she reached her maximum physical potential. Resident #1's Representative who verified having power of Attorney (POA), by providing a copy of the document to the surveyor, said that he decided to personally pay for continued skilled services. He paid the sum of $2550.00 dollars,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-02 · tag F0585 — failed to handle grievances — isolatedHonor 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 record review and interview, the facility failed to document and act upon grievances reported by 2 of 2 sampled residents (Resident #1 & Resident #2) and or their representatives in a timely manner. The findings included: Record review of the facility's grievance policy and procedures revised on 7/2024, Section #3, outlined that 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 rationale for the response. Section #7 of the policy outlined the Administrator has delegated the responsibility of grievance and or complaint investigation to the Grievance Officer. 1) Review of Resident #1's clinical record on [DATE] documented Resident #1 was admitted to the facility on [DATE]. Her admitting diagnoses included Coronary Artery Disease, Anxiety Disorder, and hypertension. The Clinical record also revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-03 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate a fall with major injury for 2 out of 3 sampled residents reviewed for Falls (Resident #2 and Resident #6). The findings included: 1) Record review for Resident #2 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing; History Of Falling; Acute Respiratory Failure with Hypoxia; Acute Posthemorrhagic Anemia; Unspecified Glaucoma; Chronic Obstructive Pulmonary Disease; Need For Assistance with Personal Care; Difficulty In Walking; and Bacteriuria, dated 03/06/24 (During Stay at Facility). Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 had a Brief Interview for Mental Status of 09, which indicated that she was moderately cognitively impaired. Review of Section GG revealed that Resident #2 required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-04 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and 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 interview and record review, the facility failed to ensure complete discharge planning was provided, related to needed and ordered home medical equipment for 1 of 1 sampled resident (Resident #1). The findings included: During a phone interview on 12/01/23 at 4:42 PM, the spouse of Resident #1 stated they were supposed to get a walker and wheelchair for home use upon discharge, but neither ever showed up. Review of the record revealed Resident #1 was admitted to the facility on [DATE] and was discharged on 09/22/23. Review of the Discharge summary dated [DATE] documented Resident #1 was to be discharged home with home health services. This Discharge Summary also documented discharge needs of DME (durable medical equipment) to include a wheelchair with elevating leg rest and cushion, along with a 3 in 1 commode (a bedside commode that can also be used over a standard toilet to provide arm support). During an interview on 12/04/23 at 3:24 PM, when asked the process for ordering and providing DME upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 review of the facility's Medical Record Request Checklist, the facility failed to follow through with a request for medical records by the resident's representative for 1 of 3 sampled residents (Resident #2). The findings included: During a phone interview on 08/09/23 at 9:50 AM, the daughter of Resident #2 stated her mother had passed away, and she had requested her mother's medical record in May of 2023. The daughter explained the medical records person had requested documentation of POA (power of attorney), which she provided. The daughter added that after the provision of the POA paperwork, she had called the facility twice asking for an update to her request, and had not received any response. Review of the record revealed Resident #2 was admitted to the facility on [DATE] and transferred out to the hospital on [DATE]. Review of the documents revealed a valid POA document was scanned into the record in May of 2023, indicating the daughter was the resident's representative and POA.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interview and record review, the facility failed to ensure resident representative participation in the care planning process for 1 of 3 sampled residents, as requested by the daughter and as needed with the resident's comprehensive assessment (Resident #2). The findings included: During a phone interview on 08/09/23 at 9:50 AM, the daughter of Resident #2 stated she had requested to be part of the care planning process from the beginning of her mother's stay at the facility (March of 2023), had asked for a care plan meeting more than once, and the facility did not have a meeting until sometime in May of 2023. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment was dated 03/17/23. The record lacked any evidence of a care plan meeting at or around the time of the admission MDS. During an interview on 08/09/23 at 4:26 PM, the Social Services Director (SSD) confirmed she and her assistant were responsible for the care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to ensure timely care and services for 1 of 2 sampled residents who had a Urinary Tract Infection (UTI). The nursing staff failed to obtain an ordered urinalysis for Resident #2 in a timely manner, failed to ensure the correct labs were completed as ordered, and failed to initiate an ordered IV (intravenous) antibiotic Vancomycin timely. The findings included: Review of the facility policy titled, Appendix E: STAT Test Menu List dated 2023 documented, The following tests are available on a STAT result basis, 24 hours a day/7 days a week. Once the facility calls in a STAT order to the Laboratory, the facility must allow 4 - 6 hours for results to be faxed to them. (Never leave a voice message requesting a STAT lab). If the facility does not receive the results in that timeline, they should contact the lab immediately. This policy further documented a Basic Metabolic Panel (BMP) as an available STAT test, but not a Comprehensive Metabolic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to dispense medications and apply biologicals for 1 of 1 sampled residents (Resident #9), as ordered by her physician. The findings included: Record review revealed Resident #9 was admitted to the facility on [DATE]. Her admitting diagnoses included: Fracture Of Right Pubis, Fracture Of Sacrum, History Of Falling, Need For Assistance With Personal Care, Difficulty In Walking, Disorders Of Bone Density And Structure, Multiple Sites; Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Migraine, Protein-Calorie Malnutrition, Major Depressive Disorder, Single Episode, and Restless Legs Syndrome. Record review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #9 obtained a score of 15/15 on the Brief Interview for Mental Status (BIMS), indicating her cognition is intact. Section G of the MDS revealed that the resident has physical impairment or restriction. She requires limited assistance for all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, records review, and interview, the facility failed to properly secure medications and biologicals for 1 of 1 sampled residents (Resident #9). The findings included: Record review revealed Resident #9 was admitted to the facility on [DATE]. Her admitting diagnoses included: Fracture Of Right Pubis, Fracture Of Sacrum, History Of Falling, Need For Assistance With Personal Care, Difficulty In Walking, Disorders Of Bone Density And Structure, Multiple Sites; Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Migraine, Protein-Calorie Malnutrition, Major Depressive Disorder, Single Episode, and Restless Legs Syndrome. Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #9 obtained a score of 15/15 on the Brief Interview for Mental Status (BIMS), indicating her cognition is intact. Section G of the MDS revealed that the resident has physical impairment or restriction. She requires limited assistance for all activities of daily living. Review of the Physicians' orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to serve food in a sanitary manner in accordance to food service safety. The findings included: During the initial kitchen tour, on 03/21/22 at 9:40 AM, accompanied by the Certified Dietary Manager (CDM, the folllowing were noted: 1). There were several single use and disposable cups on a shelf in the food preparation area 2). There was an accumulation of rust on the toaster. 3). There was an accumulation of rust and food residues on the pans on the steam table 4). There was an accumulation of food residues on and inside of the microwave oven 5). There was an accumulation of food residues and grease on the stove 6). There was an accumulation of food residues and grease on the grill 5). There was an accumulation of food residues and grease on the oven During an interview, on 03/22/22 at 2:13 PM, the CDM was informed of the findings. 6). On 03/21/22 at approximately 9:00 AM, during an observation of the residents' breakfast meals brought to the units, it was noted that the meals were delivered to the unit with carts that were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide activities to meet the needs and interests of 2 of 2 sampled residents reviewed for Activities (Resident #145 and #67). The findings included: 1. Resident #145 was admitted to the facility on [DATE]. According to the resident's most recent complete, 5-day Minimum Data Set (MDS) assessment, dated 03/16/22, Resident #145 had a Brief Interview for Mental Status (BIMS) score of 08, indicating 'moderately impaired' cognition. The MDS documented that the resident was dependent on staff for Activities of Daily Living with the exception of eating. Resident #145's diagnoses at the time of the assessment included: Anemia; Coronary Artery Disease; Hypertension; Hyperlipidemia; Non-Alzheimer's Dementia; Anxiety disorder; fracture of humerus left arm; syncope and collapse; Atrial fibrillation; Gout; Hypothyroidism. A care plan, initiated 03/10/22 documented, Patient desires to remain independent in leisure activities and participate in limited…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to identify elevated behavioral risks to prevent injury of unknown origin for 1 of 2 residents sampled for accidents (Resident #248). The findings included: Resident #248 was admitted to the facility on [DATE] from an acute care facility. Medical diagnoses included Syncope and Collapse, Hypotension, and Repeated Falls. The admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/11/22 revealed a Brief Interview of Mental Status (BIMS) of 2 indicating the resident had severe cognitive impairment. Resident #248 was taking Seroquel tablet 25 milligrams 1 daily by mouth in the afternoon for Mood Disorder prior and while she was in the facility. On 02/11/22, according to nursing progress notes, the resident left the second floor of the facility where she was staying, and went to the first floor lobby where she was found by Staff B, Licensed Practical Nurse (LPN) as she was leaving for the day. An interview was conducted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, interview and record review, the facility failed to provide medications as prescribed for 3 of 23 sampled residents (Resident#302, Resident#8, and Resident#299). The findings included: Facility Policy titled: Administration of Medications states medications will be administered within sixty minutes before or after the facility's dosing schedule. During an interview on 03/21/2022 at 11:01 AM Resident #299 stated, I developed a urinary tract infection, and it took days to get them to do anything about it. Finally, they did a urine test which showed I had an infection, and it took another day to get my medicine. Record review for Resident #299 documents she was admitted on [DATE] with diagnosis that includes back pain and recent back surgery. Her resident assessment documents a Brief Interview for Mental Status (BIMS) of 15, which indicates cognitively intact. A urinary tract infection was diagnosed on [DATE] at 4:14 PM and antibiotics (Macrobid) was ordered to be given twice a day. At…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy, observation, record review and interview the facility failed to maintain glucometers per manufacturers instruction for 3 of 3 glucometers sampled. The findings included: Facility Policy Titled Blood Glucose Monitoring dated May 2021 states: Quality control assessment and calibration shall be completed as recommended by the manufacturer. Facility blood glucose meter quality control log states do not proceed with patient testing until both daily controls are within acceptable ranges and documented. High and low control solutions must be run daily when meter is in use, when using new lot number of test strips or controls. Manufacturer's instructions for use for the facility glucometer state check glucometer using the dose control solution when a new bottle of test strips is opened. Manufacturer's instructions for the facility glucometer control solution state discard after 3 months from opening date. On 03/23/2022 at 10:38 AM, during a medication cart #6 review, accompanied by Staff W, the glucometer control solution was noted to be labeled opened 6/1/21. 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.
- No harm found · B2022-03-24 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to employ a qualified Infection Preventionist who completed specialized training in infection prevention and control. The findings included: On 03/23/22 at 2:00 PM an interview was conducted with the Director of Nurses (DON) regarding infection control. The DON informed the survey team that she was the Infection Preventionist. During the interview, she was asked to see her certification for specialized training in infection prevention and control. The DON responded that she did not have certification but the facility is hiring an Assistant Director of Nurses who will take over the role of Infection Preventionist and she has certification. She further stated that she will be starting in a month. At the time of the survey, no one in the facility had specialized training in infection prevention and control.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$58,835 in federal fines across 1 penalty.
- $58,835 — penalty dated 2025-04-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WELLINGTON REHAB HOLDING PARTNERS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/14/2020 |
| SCHUSTER, RACHEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| JEROME, GERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/27/2025 |
| MACFARLANE, KERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/24/2025 |
| PARNES-DE-LUCE, PEARL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/16/2025 |
| SHERMAN, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2023 |
| FRIEDMAN, LEOPOLD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/05/2025 |
| ASTON HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| LUXE CONSULTING GROUP LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 13 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.
This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106091. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-27, 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.