Aviata At West Palm Beach
5065 Wallis Road, West Palm Beach, FL 33415 · For profit - Corporation · 120 certified beds · (561) 689-1799 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,790 in federal fines (most recent 2026-03-13)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 1.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.9% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.1% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.5% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.0% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.2% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 3.9% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.7% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.9% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.7% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.5% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.39 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.29 | 1.15 | 1.80 | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 112.7 residents a day — about 94% occupied, or roughly 7 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.547 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.15 hrs/resident/day on weekends vs 3.42 on weekdays — 8% thinner on weekends. RN hours go from 0.62 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2026-03-13 · 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 record review and interview, the facility neglected to honor a resident's full code status and failed to perform emergency care/cardio-pulmonary resuscitation (CPR) on 1 of 3 residents reviewed for advanced directives (Resident #1). The facility did not perform basic life support according to the physician's orders and advanced directives and the resident died. The staff neglected to inform administration of the incident. The Immediate Jeopardy began on [DATE] at 11:15 PM. The Immediate Jeopardy was removed effective [DATE]. The facility self-identified the serious incident as noncompliance that was Immediate Jeopardy and took immediate actions to remove the Immediate Jeopardy on [DATE]. The facility continued to implement corrective actions until they achieved substantial compliance for F600. During the survey, the facility provided to the surveyor a corrective action plan. The surveyor verified the facility's corrective actions to correct the noncompliance for F600 on [DATE], prior to the survey…
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.
- Immediate jeopardy · J2026-03-13 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 honor a resident's full code status and failed to perform emergency care/cardio-pulmonary resuscitation (CPR) on 1 of 3 resident's reviewed for advanced directives (Resident #1). The facility did not perform basic life support according to the physician's orders and advanced directives and the resident died. The Immediate Jeopardy began on [DATE] at 11:15 PM. The Immediate Jeopardy was removed effective [DATE]. The facility self-identified the serious incident as noncompliance that was Immediate Jeopardy and took immediate actions to remove the Immediate Jeopardy on [DATE]. The facility continued to implement corrective actions until they achieved substantial compliance for F678. During the survey, the facility provided to the surveyor a corrective action plan. The surveyor verified the facility's corrective actions to correct the noncompliance for F678 on [DATE], prior to the survey visit.F678 was determined to be past noncompliance as of [DATE]. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure timely and appropriate care and services for 5 of 27 sampled residents as evidenced by the failure to provide wound care for non-pressure wounds for Residents #9, #76, and #110; failure to complete weekly skin assessments for Residents #9, #76, #110 and #10; failure to provide supplies and treat edema as ordered for Residents #76 and #110; and failure to administer medications as ordered for Resident #13. The findings included: 1) Review of the record revealed Resident #9 was readmitted to the facility on [DATE] with diagnoses to include Diabetes, Morbid Obesity, Congestive Heart Failure, and Non-Pressure Chronic Ulcer of the Right Lower Leg. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. a) Review of the current physician ordered wound care dated…
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 · D2025-09-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews, the facility failed to provide care and services for a pressure ulcer as evidenced by not following physician orders to treat a facility acquired pressure ulcer for 1 of 2 sampled residents (Resident #10).The findings included:Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment.Review of the quarterly care plan dated 08/16/25 revealed a focus that Resident #10 had skin impairment to the sacrum with a goal to promote healing with intervention of staff to administer treatments as ordered and monitor for effectiveness. Review of a wound care consultation note dated 07/03/25, documented that Resident #10 had an unstageable pressure ulcer to her sacrum that measured 5.5cm x 5.0cm x 0.2cm with 90% necrotic tissue.Review of a physician order dated 08/16/2025 instructed staff 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.
- Potential for harm · Dcited before2025-09-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to provided care and devices in order to prevent a decrease in range of motion for 1 of 1 resident reviewed for position/mobility, Resident #23. The findings included:Record review for Resident #23 revealed an admission date of 11/29/24. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), with a reference date of 08/28/25, Resident #23 was not assessed for cognition due to 'resident is rarely/never understood'. The assessment documented that Resident #23 was dependent upon staff for all Activities of Daily Living (ADLs). Resident #23's diagnoses at the time of the MDS included: Anemia, Coronary Artery Disease, Diabetes Mellitus, Aphasia, Non-Alzheimer's dementia, Seizure disorder, Respiratory failure, Aphasia following Cerebrovascular accident, Dysphagia, Gastro Esophageal Reflux Disease (GERD), Contracture of left elbow. Resident #23's orders included:Restorative: Left elbow splint, 8hrs as tolerated - 11/30/24.Further review of resident's record revealed no…
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 · D2025-09-25 · 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 observations, interviews, and record review, the facility failed to provide a Reacher for 1 out of 1 resident reviewed for Accidents (Resident #13). The findings included:Record review for Resident # 13 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease, a condition caused by damage to the airways or other parts of the lung, Low Back Pain, Unspecified Dementia, a medical term used for memory loss and confusion, but the cause of the decline cannot be determined and Age Related Osteoporosis without pathological fracture, a condition of progressive bone loss and reduced bone strength due to aging, which increases the risk of future fractures, but in the absence of a current fracture.Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident # 13 had a Brief Interview for Mental Status of 14, which indicated that she was cognitively intact. Review of Section GG of the MDS dated [DATE] 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 · Dcited before2025-09-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, observations and interviews, the facility failed to provide treatment and services to prevent complications of enteral feeding (food delivered through a gastric tube) for 1 of 4 sampled residents as evidenced by failure to ensure aspiration (inhaling food or liquid in the airway) precautions for Resident #10 during enteral feeding.The findings included:Review of the facility policy titled Enteral Feeding-Enteral Nutrition Pump revised 11/12/18, documented in part Procedure: Assist resident to semi-Fowler_position (head and upper body raise 30-45 degrees) or turn on his or her right side. Record review revealed Resident #10 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 99 on a 0-15 scale indicating severe cognitive impairment. Review of medical history revealed a diagnosis of stroke and dysphagia (difficulty swallowing).Review of the quarterly care plan dated…
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 · D2025-09-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 facility policy review, record reviews, observations, and interviews the facility failed to provide care and services for nebulizer and tracheal suctional for 3 of 3 sampled residents, as evidenced by failure to follow procedure for tracheal (opening that connect voice box to passage to airway) suctioning (remove secretions to keep airway open) and physician order for administration of oxygen for Resident #10, failure to follow physician orders for administration of nebulizer treatment and storage of nebulizer equipment for Resident #94, and failure to store nebulizer equipment properly for Resident #39. The findings included:Review of the facility policy titled Tracheal Suctioning revised 08/24/17, documented in part Tracheal suctioning is an effective way to maintain a clear airway and to aide in the removal of secretions for residents who are unable to clear their secretions with coughing. Procedure: Hyperventilate the resident either manually or mechanically for a few breaths. Assess resident…
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 · D2025-09-25 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility assessment, staffing record review, and interview, the facility failed to ensure sufficient staff on 6 of 13 weekends reviewed as evidenced by failure to staff as per their facility assessment, failure to ensure provision of wound care on weekends and during the survey for 3 of 4 sampled residents (Residents #9, #10, and #76), and as evidenced by 11 grievances related to patient care logged from April 2025 to the survey date.The findings included:Review of the federal staffing numbers submitted for the third fiscal quarter of 2025 (04/01/25 through 06/30/25) revealed low weekend staffing.Review of the Facility Assessment, revised 02/19/25, documented a general staffing plan to meet resident needs as follows:a) The ratio of licensed nurses to residents on day shift would be 1:22 (7 AM to 3 PM).b) The ratio of licensed nurses to residents on the evening shift would be 1:29 (3 PM to 11 PM).c) The ratio of licensed nurses to residents on night shift would be 1:29 (11 PM to 7 AM). Note the nurses at this facility work 12 hours shifts, from 7 AM to 7 PM and 7 PM to 7…
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 before2025-09-25 · 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 observations, record reviews, and interviews, the facility failed to ensure standards of practice for administration of medication for 2 of 27 samples residents, as evidenced by failure to ensure medications not left at the beside for Resident #39 and Resident #14.The findings included:1) Record review reveal Resident #39 was admitted to the facility on [DATE]. Review of the quarterly assessment documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scaled, indicating no cognitive impairment. During an observation on 09/22/25 at 10:50 AM, Resident #39 was noted sleeping in his bed. A clear medication cup with 2 white capsules was observed on his bedside table.During an interview 09/22/2025 3:22 PM, when asked did you take the pills that were left in a medicine cup on your bedside table, Resident #39 he stated. Yes. When asked do you know what the medications was for, he stated, I pretty much know the medications I take when I see them and if it's something I don't recognize, I will let…
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 before2025-09-25 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to monitor behaviors and side effects of medications used for mood disorder, for 1 of 5 sampled residents, Resident #9. The findings included: Review of the record revealed Resident #9 was readmitted to the facility on [DATE] with a diagnosis to include Post Traumatic Stress Disorder (PTSD). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. Review of the current orders revealed Resident #9 had been receiving Valproic Acid 500 milligrams (mg) three times daily since 06/25/25 for a mood disorder. Review of the September 2025 Medication Administration Record (MAR), the Treatment Administration Record (TAR), and corresponding nursing progress notes lacked any documented side effect or behavior monitoring for the Valproic Acid. During an interview on 09/22/23 during…
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 · D2025-09-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, record reviews and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 17.14% (6 errors) with 35 opportunities due to failure to ensure that Resident #85 and Resident #42 received medications as ordered and were available.The findings included:1) During an observation of medication administration on 09/24/25 at 8:53 AM, Staff K, LPN prepared a total of 7 pills for Resident #85. She stated, I do not have the inhalers to administer, because they have not arrived from the pharmacy. I will have to call pharmacy to follow up. When asked which inhalers you don't have, Staff K stated The Mometasone and Budesonide. The resident just told me that he hasn't had them for a few days. Staff K, LPN entered the resident's room to administer the medications she had prepared. The resident asked if his gout medication was in the medicine cup, she stated, Yes, the allopurinol is in there. Staff K, LPN told the resident that she will follow up on getting the inhalers reordered.…
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 20 citations
- Potential for harm · Dcited before2025-09-25 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, interviews and record reviews, the facility failed to provide foods prepared in a sanitary manner and in accordance with professional standards for food safety. The findings included:1. During the initial kitchen tour, on 09/22/25 at 9:01 AM, accompanied by the Dietary Manager, the following were noted: a. The concentration of the quaternary ammonia used for sanitizer in a red bucket in the processing area was less than 200 parts per million necessary to sanitize food equipment and surfaces.b. The paint was peeling from the wall at the left of the door in the dry storage area.c. The ceiling over the reach in freezer #2 was damaged in a manner indicative of being wet.d. There was an accumulation of dust and condensation on the vents of the air conditioning unit in the dry storage area.e. Cleaned and sanitized pitchers used to provided fluids to the residents during meals had residue left from the date stickers that were placed on them.f. The hand washing sink was not sealed to the wall as the caulk had appeared to have worn.g. There was an accumulation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-01 · 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 record review and interview, it was determined, the facility staff failed to provide necessary care and services for 1 of 2 sampled residents (Resident #1), who required antibiotic therapy and monthly catheter changes to minimize risk of infection. The findings included: Clinical record review conducted on 04/01/25 revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses including Paraplegia and Urinary Tract Infection. Minimum Data Set, quarterly assessment with reference date 12/20/24, documents the resident was assessed as independent for skills of daily decision making, is staff dependent for personal hygiene, bathing, dressing and toileting and has an indwelling urinary catheter. Care Plans implemented for Resident #1 and revised 12/30/24 included the following: Paraplegia, resident has Spinal Injury related to trauma with potential for decline in self care. The approaches noted give medications as ordered and monitor document for side effects and effectiveness. Risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-31 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interviews and record reviews, the facility failed to provide foods prepared under sanitary conditions and in accordance with standards for food safety professionals. The findings included: 1). During the initial kitchen tour, on 05/28/24 at 8:48 AM, accompanied by the District Manager for Health Services Group (contracted to oversee the kitchen/dietary ) the following were noted: a. An employee's personal cellular device on prep table by the walk in cooler. b. There was an accumulation of food residue on the sharpening stones to slicer. c. A 1/3 sized six inch deep container of barbecued pork in the process of cooling from the previous day was 49 degrees Fahrenheit (F). The District Manager confirmed that the pork was in the process of cooling from being served the day before. d. A 1/3 sized six inch deep container of meatballs in the process of cooling from the previous day was 51 degrees F. The District Manager confirmed that the meatballs were in the process of cooling from being served the day before. e. In the food services area, the wall to the left of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-31 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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, observation, and record review, the facility failed to provide toenail care, in a timely manner for 1 (Resident #67) of 1 resident reviewed for foot care. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnosis in part to include: End stage Renal Disease with dependence on renal dialysis, unspecified Protein Calorie Malnutrition, Atrial Flutter, Bilateral Non Pressure Wounds of Lower Extremities, Anemia, Hypertension, Major Depressive Disorder and difficulty in walking. On 03/07/24 Resident #67 had an MDS (Minimum Data Set) assessment. The resident had a BIMS (Brief Interview for Mental Status) of 15, which indicates the resident is cognitively intact. The assessment also indicated the resident needed assistance with bathing, dressing and putting on and taking off footwear. On 05/28/24 at 1:50 PM, an interview was conducted with Resident #67. The resident was sitting outside in a wheelchair. He was wearing sandals. His toenails were observed. His right and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, the facility failed to assess and provide Range of Motion (ROM) as requested by the resident for 1 of 1 resident reviewed for ROM (Resident #53). The findings included: Resident #53 was admitted to the facility originally on 08/24/22. Diagnoses included Guillain-Barre Syndrome, Type 2 Diabetes, Osteoarthritis, and Paraplegia. Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/26/24. Section O of the MDS revealed she has not received Physical therapy (PT), Occupational therapy (OT) or ROM in the last 7 days. Section GG of the MDS revealed her functional abilities was limitation in ROM on both sides. On 05/28/24 at 1:25 PM, an interview was conducted with Resident #53. She stated she was in the facility because she never recovered from Guillain-Barre. Guillain-Barre causes your immune system to attack your nerves, leading to symptoms such as weakness, tingling, numbness, and paralysis. She stated she feels like if she does not have ROM she will get…
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 · D2024-05-31 · 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 observation, interview, record and policy review, the facility failed to maintain a PICC (Peripherally inserted central catheter) line in a sanitary manner for 1 of 1 resident sampled for PICC lines (Resident #375). The findings included: The facility's policy titled, Catheter Insertion Care effective 1/17/2019 revealed Change midline catheter dressing 24 hour after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Resident # 375 was admitted to the facility on [DATE] with diagnoses that included Acute Osteomyelitis of the left ankle and foot, Pressure Ulcer of the left heel and Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere. A Brief Interview for Mental Status (BIMS) was done on 05/13/24 and the resident scored a 15, which indicated he was cognitively intact. On 05/28/24 at 11:00 AM, Resident #375 was interviewed and a PICC line was observed on the resident's left upper arm. The dressing was covered…
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 · D2024-05-31 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to adhere to fluid restrictions for 1 of 2 residents reviewed for dialysis (Resident #37). The findings included: Resident #37 was initially admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual Minimum Data Set (MDS), date 03/23/24, Resident #37 had a Brief Interview for Mental Status score of 11, indicating that Resident #37 was moderately cognitively impaired and that the resident required setup help only for eating. Resident #37's diagnoses at the time of the assessment included: Anemia, Diabetes, Heart Failure, Hyperkalemia, Peripheral Vascular Disease, Thyroid disorder, Anxiety Disorder, Depression, Chronic Lung Disease, Disorders of Calcium Metabolism, Gangrene, Insomnia, Extrapyramidal and Movement Disorder, Long term use of insulin, Dysthymic Disorder. Resident #37's care plan for nutrition, initiated on 05/27/20 and most recently revised on 04/17/24, documented, The resident has…
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 before2024-03-19 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 provide 1 of 1 (Resident #1) sampled residents with foot care and treatment in accordance with professional standards of practice , including to prevent complications from the resident's medical condition. The findings included: During an observation conducted of Resident #1 on 03/19/24 at 11:15 AM and accompanied with the Director of Nursing (DON) and Assistant Director of Nursing , the resident was asked permission by the DON and granted permission to have both feet examined. The examination noted the following: < Observation of the Left foot noted that the sock was caked with a black substance and was noted difficult to peel the sock away from the foot. The resident was noted to have pain/discomfort during the sock removal. Photographic evidence obtained. < Observation of the Left foot noted the entire top surface and toes to be covered with thickened, brown/black scaly type matter and had an offensive odor. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to document the accuracy of code status for 1 of 28 sampled residents reviewed for code status (Resident #43). The findings included: Review of Resident #43 electronic records revealed the resident was admitted [DATE] with a diagnosis to include Dementia, Cerebral Vascular Accident, Type II Diabetes, Aphasia, Hemiplegia and Hemiparesis, Adult Failure to Thrive, Atrial Fibrillation, and Convulsions. Review of the resident's quarterly MDS (Minimum Data Set) dated 01/31/23 revealed the resident has a BIMS (Brief Interview for Mental Status) of 7, indicating his cognition was severly impaired. Review of the resident's MAR (Medication Administration Record) documented Resident #43 is a Full Code, which indicated if this resident's heart stopped beating or he stopped breathing, all resuscitation procedures would be provided to keep them alive. Review of the physicians' orders dated 07/13/20 documented the resident is a full code and there was also a Do…
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 · D2023-03-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment in 3 of 4 units, including the laundry room; and failed to ensure an environment free of accident hazards by not securing disposable razors at the bedside for 1 of 28 sampled residents (Resident #42). The findings included: Observations during the survey on 03/13/23 through 03/16/23, revealed the following concerns on 3 of 4 units. A tour of the facility was completed on 03/16/23 at 1:41 PM with the Maintenance Director and the Plant Ops (Operations) Assistant who acknowledged the concerns below during the tour: 1. room [ROOM NUMBER]: There was rust around the light switch cover by inside the room by the door; and there was paint peeling on the back wall behind the bed. room [ROOM NUMBER]: There was paint peeling on the wall, caulking needs to be done under chair railing, wall behind bed had paint peeling, two tone paint on wall behind bed, A/C (air conditioner) unit base was cracked, wood…
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 · D2023-03-16 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 1 of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) was screened for a mental disorder or intellectual disability prior to admission (Resident #41). The findings included: Resident #41 was first admitted to the facility on [DATE]. On 10/26/21, the resident to a hospital for lethargy and fever. Resident #41 was re-admitted on [DATE] under Hospice services. At the time of re-admittance, Resident #41 had diagnoses that included Coronary Artery Disease, Anxiety Disorder, Major Depressive Disorder, Schizophrenia and Psychosis. The Quarterly Minimum Data Set (MDS) assessment, dated 02/17/23, documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 11, indicating minor cognitive impairment. The resident's Mood was documented as showing little interest or pleasure in doing things; feeling down, depressed or hopeless; having sleep issues; and feeling tired or having little energy. There were no…
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 before2023-03-16 · 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 observation, policy review, clinical record review and interview, the facility failed to identify, report and treat skin conditions in a timely manner for 1 of 1 sampled resident reviewed for skin conditions (Resident #25); and the facility failed to follow physician's orders for medication administration for 1 of 5 sampled residents (Resident #10) during medication administration observation. The findings included: Facility policy, titled, Skin Evaluation, last revised 04/01/17 documents A Licensed Nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas and skin problems. Procedure: a Licensed Nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form. If the resident is assessed as having a skin problem, the evaluating nurse will…
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 before2023-03-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer and adequately document tube feedings as ordered by the physician for 1 of 1 sampled resident reviewed for tube feeding (Resident #28). The findings included: Review of the facility's policy, titled, Enteral Feeding -Enteral Nutrition Pump, with a revision date of 11/12/18, included: Nurses administer enteral feeding when volume control is indicated and as ordered by physician. Review of the facility's policy, titled, Physician Orders, with a revision date of 03/03/21 included: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the facility's policy, titled, Medication Administration Via Enteral Tube, with a revised date of 03/06/19, included: Document on the Nurse's Notes any problems encountered and any measures taken. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE].…
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 before2023-03-16 · 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
Based on record review and interview, the facility staff failed to: Acquire and dispense medications in a timely manner for 1 of 28 residents (Resident #62); and failed to ensure narcotic reconciliation was accurate for 3 of 3 sampled residents (Resident #2, #71, and #68). The findings included: 1. Facility policy, titled, Medication Shortages/Unavailable Drugs, dated 12/01/07, documented: This Section 7.0 sets forth procedures relating to medication shortages and unavailable drugs. PROCEDURE 1. Upon discovery that the Facility has an inadequate supply of a medication to administer to a resident, Facility Staff should immediately initiate action to obtain the medication from the Pharmacy. 1.1 If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take the action specified in Sections 2 or 3 of this Section 7.0, as applicable. 2. If a medication shortage is discovered during normal Pharmacy hours: 2.1 A licensed Facility nurse should call the Pharmacy to determine the status of the order. If the medication has not been…
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 · D2023-03-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the consultant pharmacist failed to identify irregularities for the use of 'as needed' anxiolytic medication for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #3). The findings included: Facility policy, titled, Administering Medications, last revised April 2019, documented Administering Medications: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 28. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Clinical record review conducted on 03/13/23 revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. Physician's…
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 before2023-03-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview, the facility failed to ensure medication regimen was free of unnecessary medications of 1 of 7 sampled residents (Resident #46), as evidenced by failure to monitor and follow parameters for insulin administration. The findings included: Facility policy, titled, Administering Medications, last revised April 2019, documented: Administering Medications Medications are administered in a safe and timely manner. and as prescribed. Policy Interpretation and Implementation 1. only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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, policy review and interview, the facility failed to ensure residents receiving PRN (as needed) orders for psychotropic drugs were limited to 14 days unless there was documented rationale in the resident's medical record to indicate the reason for the extended duration, for 3 of 7 sampled residents (Resident #2, #3, #22); and facility staff failed to implement behavior monitoring for Resident #2, who is receiving anti-anxiety medications, including the identification of the target behavior and the provision of non-pharmacological interventions prior to medication use. The findings included: 1. Clinical record review conducted on 03/14/23 revealed Resident #2 was re-admitted to the facility on [DATE] with multiple medical conditions. Minimum Data Set, assessment with reference date 12/11/22 documented the resident was assessed as independent for skills of daily decision making; required extensive assistance with activity of daily living and received antiquity and opioid medications. Care…
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 · D2023-03-16 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete annual performance reviews for 3 of 3 sampled staff members (Certified Nursing Assistants / CNAs, Staff #G, #H and #I) The findings included: Review of the personnel files provided on 03/16/23 revealed Staff #G, Certified Nursing Assistant (CNA), was hired on 04/01/22; Staff #H, CNA, was hired on 05/31/07 and Staff #I, CNA, was hired on 07/01/20. Review of the documentation provided revealed no evidence that Staff #G, #H and #I had evidence of completing the required continuing competency education of no less than 12 hours per year. Interview with the Assistant Director of Nursing (ADON) conducted on 03/16/23 at approximately 1:00 PM revealed the facility completed abuse and dementia training for the staff. The ADON explained some of the education is completed in classroom setting and some through Relias academy. The ADON was not able to provide evidence of the completion of the required competencies and education for the staff identified above to meet the 12 hour credit requirement or to explain the system 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.
- No harm found · B2023-03-16 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete annual performance reviews for 2 of 3 sampled staff members (Certified Nursing Assistants, Staff #H and #I). The findings included: Review of the personnel files provided on 03/16/23 revealed Staff #H, Certified Nursing Assistant, was hired on 05/31/07 and Staff #I, a Certified Nursing Assistant was hired on 07/01/20. Review of the documentation provided revealed no evidence that the Certified Nursing Assistants, Staff #H and #I had annual performance reviews. Interview with Assistant Director of Nursing (ADON) conducted on 03/16/23 at approximately 1:00 PM revealed the facility completes annual evaluations and was asked to provide the most recent performance reviews for Staff #H and #I. The information was not provided. Subsequent interview with the Human Resources Director on 03/16/23 at approximately 2:49 PM revealed nursing is responsible for the completion of the annual evaluations and was not able to provide evidence of completion. Interview with the Administrator during the exit conference revealed 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 · B2023-03-16 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
Based on record review and interviews, the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on 3 of 28 sampled residents that are complete and accurately documented (Residents #20, #53, and #64). The findings included: 1a. Upon review of the March 2023 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for Resident #20, it was noted that staff initials and charting codes were missing for the following medication administrations and treatments: a) 03/03/23 at 9:00 AM - Enoxaparin Sodium Pre-Filled Injection Syringe 60 mg. b) 03/03/23 at 6:00 PM - Lacosamide 100 mg for seizures Lasix 40 mg for Congestive Heart Failure Potassium Chloride Oral Solution 15 ml for Congestive Heart Failure. c) 03/04/23 at 5:00 AM - Enteral Feeding (Isosource 1.5, 480 ml per day). d) 03/07/23 at 9:00 AM - Bisacodyl EC Tablet Delayed Release 5 mg Oxygen Saturation not recorded Lisinopril 10 mg for Hypertension Enoxaparin Sodium Pre-Filled Injection Syringe 60 mg. Ivabradine HCI 5 mg 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.
“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
$33,790 in federal fines across 3 penalties.
- $13,065 — penalty dated 2026-03-13
- $13,065 — penalty dated 2026-03-13
- $7,660 — penalty dated 2025-09-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to AVIATA HEALTH GROUP — 50 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 49 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 49; lowest-rated first.
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 / manager | Type | Role | Since |
|---|---|---|---|
| WALLIS PARENT LLC | Organization | DIRECT OWNERSHIP INTEREST | since 11/02/2023 |
| AZALEA PALM HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/02/2023 |
| FREUND, NOCHUM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/02/2023 |
| BLACKMAN, RUSSELL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/17/2025 |
| RODRIGUEZ, YANITZA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/21/2024 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| HERSKOWITZ, ELIEZER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| HERSKOWITZ, YAAKOV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| TRAVITSKY, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| ASPIRE MGT LLC | Organization | ADP OF THE SNF | since 11/02/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $111K 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
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 105558. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, 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.