Beach Breeze Rehab And Care Center
1626 Davis Rd, West Palm Beach, FL 33406 · For profit - Corporation · 120 certified beds · (561) 439-8897 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0568)
- 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
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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 | 2.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.5% | 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 | 1.1% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.7% | 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 | 21.4% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.9% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.42 | 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.
35.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.1% 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 138 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 35.8%CMS range 23.5–48.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.5–17.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.1% | 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 | 56.5% | 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 | 38.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 100.0% | 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 | 0.9% | 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 | 1.8% | 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 | 8.8%CMS range 5.0–17.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 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 109.9 residents a day — about 92% occupied, or roughly 10 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.59 on weekdays — 7% thinner on weekends. RN hours go from 0.89 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Fcited before2025-05-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to follow proper sanitation practices in the provision of food for the residents. This had the potential to affect 109 Residents on oral diets. The findings included: A). A tour of the main kitchen was conducted on 05/05/25 at 9:30 AM. The surveyor was accompanied by the Food Service Director (FSD) and the Registered Dietitian. The following was observed: 1. The [NAME] Convection oven had brown residue on the exterior of the oven in the area near the door hinge and on the door handles. 2. The Sunfire oven had brown residue on the exterior of the oven, the door's handle, and on an open ledge located beneath the turn on/off control knobs. 3. The Cleveland Steamer had brown residue stuck on the valve open/close knob. 4. The meat slicer was dirty with debris located on the interior surface below the blade. 5. In the walk-in refrigerator the following items were expired: a. Two one-pound boxes of butter were dated 11/11/24 (brand: Challenge). b. A package 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 · E2025-05-08 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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, interview, and record review the facility failed to treat Residents with dignity and respect during care for Residents #323, #20, and a Resident that wished to remain anonymous; failed to discuss financial concerns in private for Resident #94; and failed to treat Residents with dignity during dining for Residents #8, #74, #76 and #104. The findings included: Review of the policy titled Guideline: Administrative-Resident Rights-Right to Respect, Dignity and to have Personal Property documented Process: 1. The resident has a right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. 1. Review of the record revealed Resident #323 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #323 had a Brief Interview for Mental Status (BIMS)…
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 before2025-05-08 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, interview, and review of housekeeping records, the facility failed to ensure a safe, clean, and homelike environment for 1 of 4 units ([NAME]) as evidenced by pervasive odors noted on the unit throughout the survey week and maintenance concerns in the dining room. The findings included: 1) During an interview on 05/08/25 at 1:29 PM, when asked how she ensures an odor-free environment, the Housekeeping Manager stated her staff utilize a disinfectant cleaner to wipe down all surfaces, and during a deep cleaning of a room, all linens and curtains were changed out. When asked the process and schedule for deep cleaning the rooms, the Housekeeping Manager explained she had a schedule in which one or two rooms were deep cleaned daily, and when a resident was discharged , that room was also deep cleaned. When asked if there were any additional considerations for the [NAME] unit, which was the secured unit for the memory impaired residents, the Housekeeping Manager stated the housekeeper assigned 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 · E2025-05-08 · 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 observations, interviews, and record reviews, the facility failed to have sufficient staff to intervene when 2 residents (#92, #76) ate or drank from 5 other residents' cups or plates, and when 1 resident who preferred to remain anonymous, reported that the [NAME] Hall was chaotic on the weekends. This had the potential to affect 31 residents in the [NAME] Hall, memory support unit. The findings included: During an interview conducted on 05/06/25 at 9:20 AM, as a part of the initial screening process, a resident who wanted to remain anonymous said that [NAME] Hall needed more staff during weekends. She described the environment on the weekends as chaotic. A record review revealed that Resident #92 was admitted to the facility on [DATE]. Her medical history included Alzheimer's Disease, Unspecified Dementia, Anxiety Disorder, Oral Dysphagia, and Cognitive Communication Deficit. These diagnoses were present on admission. A review of the Minimum Data Set (MDS) annual assessment 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 · D2025-05-08 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to honor a resident's choice to have information displayed in the resident's room for 1 of 2 residents reviewed for choices, Resident #117. The findings included: Resident #117 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an admission Minimum Data Set (MDS) with a reference date of 04/13/25, Resident #117's preferred language was Spanish. The MDS documented that Resident #117 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was 'cognitively intact'. Resident #117's diagnoses at the time of the assessment included: Stroke, Non-Alzheimer's dementia, Malnutrition, Depression, Nontraumatic intracranial hemorrhage, Dysphagia, Dysarthria and Spinal stenosis. Resident #117's care plan for communication documented, Resident has a potential communication problem related to language barrier. He is Spanish speaking. Date Initiated: 04/09/2025 Revision on:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 provide a receipt for a financial transaction as evidenced by Resident #94 stating he did not sign or receive a copy of a receipt. The findings included: Review of the policy titled Resident Rights-Personal funds effective 04/01/2022, documented, in part, A resident who requests cash with available funds will be given cash or check and a signed receipt will be provided for both resident and records. Record review revealed Resident #94 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status score of 15, on a 0-15 scale, indicating no cognitive impairment. During an interview on 05/05/25 at 9:59 AM, when asked if everyone is treating you well at the facility, Resident #94 stated, I have an issue with the social worker regarding my social security. They gave me some money in January, but I haven't received any since. 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.
- Potential for harm · D2025-05-08 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 interviews, the facility failed to provide the resident with his original documents upon request for 1 of 2 sampled residents (Resident #56); and the facility failed to deliver mail to 1 of 2 sampled residents (Resident #94). Findings included: The review of the policy titled Communication with You and Friends, documented, in part You will receive mail addressed to you delivered at the facility unopened, and as soon as possible. 1. Record review revealed Resident #56 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15 scale, indicating no cognitive impairment. During an interview on 05/05/25 12:27 PM, the resident stated the Office Manager brought her these forms last Tuesday and she asked for the originals. The Office Manager said we don't have originals. I know these are not original because the bottom is cut off 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 before2025-05-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a care plan for a resident's smoking for 1 of 2 residents reviewed for smoking (Resident #31). The findings included: The facility's Smoking Policy, with no reference date, documented: Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Resident #31 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, the admission Minimum Data Set (MDS), with a reference date of 04/5/25, Resident #31 had a Brief Interview for Mental Status (BIMS) score of 09, indicating that the resident was 'moderately' cognitively impaired. The assessment documented that Resident #31 required partial/moderate assistance for bed mobility, substantial/maximal assistance for transfers and ambulated via manual wheelchair independently. Resident #31's diagnoses…
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 before2025-05-08 · 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 observations, interviews and record reviews, the facility failed to: 1). Provide alternate means for a resident to communicate with staff for 1 of 2 residents reviewed for communication, Resident #117; and 2). Failed to ensure a resident was provided with appropriate supplies in order to independently maintain their ostomy for 1 of 1 resident reviewed for ostomy status, Resident #323. The findings included: 1). Resident #117 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, the admission Minimum Data Set (MDS) with a reference date of 04/13/25, Resident #117 was 'Hispanic, Latino or Spanish origin' and preferred language was Spanish. The MDS documented that Resident #117 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was 'cognitively intact'. The MDS documented that Resident #117 required 'Substantial/maximal assistance' for bed mobility, was dependent upon staff for transfers and ambulated via manual wheelchair 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 · D2025-05-08 · 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 observations, interviews, and record reviews, the facility failed to provide activities designed to meet the interests of one resident (Resident #84), to promote the psychosocial well-being of that resident. This had the potential to affect 31 residents in the [NAME] Hall, memory support unit. The findings included: A record review revealed Resident #84 was admitted to the facility on [DATE]. Her history of diagnoses included Dementia, Mood Disturbance, Anxiety, and Mood Disorder due to Known Physiological Condition. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #84 had a Brief Interview for Mental Status (BIMS) score of 10. This indicated that she had moderate cognitive impairment. A review of Section E revealed that Resident #84 exhibited no behaviors that quarter. A review of Resident #84's ongoing care plan initiated 07/30/24 stated that she had a history of trauma; and she required adequate time to make choices related to her care. One intervention…
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 before2025-05-08 · 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 collaborate with Hospice services for 1 of 1 sampled resident, Resident #95, as evidenced by contradictory code status documentation. The findings included: Review of the record revealed Resident #95 was admitted to the facility on [DATE], with a subsequent admission to Hospice services as of 01/16/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident was cognitively impaired. Review of the same assessment documented the resident had a terminal diagnosis and was on Hospice services. Review of the current electronic medical record (EMR) documented Resident #95 had a full code status, as noted on the banner or general information area of the EMR, meaning cardiopulmonary resuscitation would be initiated should the resident become unresponsive and without a heartbeat. A current order dated 03/19/25 also documented 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 before2025-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that proper protocol was implemented when a resident has a fall, as evidenced by not reporting or following up on a fall for Resident #35. The Findings included: Record review revealed Resident #35 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status score of 03, on a 0-15 scale, indicating severe cognitive impairment. During an interview on 05/05/25 at 10:42 AM, Resident # 56 (who is the roommate of Resident #35), stated My roommate fell out of bed a couple of nights ago, she was trying to change the air conditioner. I had to call for help and it took them a while to get here. I guess they were busy with someone else. I told Resident #35 not to move, because I know what can possibly happen if she moves. When asked who got Resident #35 off the floor, Resident #56 stated Two staff, the nurse and the aide. She fell really…
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 before2025-05-08 · 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 observations, interviews and record reviews, the facility failed to provide nutrition via enteral method as ordered for 1 of 4 residents reviewed for tube feeding (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), with a reference date of 02/06/25, Resident #5 was not assessed for cognition due to 'Resident is rarely/never understood'. Resident #5's diagnoses at the time of the assessment included: Cancer, Hypertension, Diabetes Mellitus, Non-Alzheimer's dementia, Psychotic disorder, Hypothyroidism. Resident #5's orders included: Nothing by Mouth (NPO) - 11/14/24 Enteral Feed - in the afternoon Enteral feeding type: Jevity 1.5 via G tube to run at 60 ml/hr (milliliters per hour) via PUMP. Total volume to be infused:1200ml/20hrs. Up at 2pm and down when Total Volume is infused. AND every shift Check and ensure accurate rate and feeding (Jevity 1.5 via G tube at 60 ml/hr…
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 before2025-05-08 · 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 observation, interview, and record review the facility failed to perform a respiratory assessment on a resident with respiratory treatments for 1 of 2 sampled residents (Resident #54). The findings included: Review of the record revealed that Resident #54 was admitted [DATE] with the primary diagnosis of Chronic Obstructive Pulmonary Disease (a lung disease causing restricted airflow and breathing problems.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #54 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 active orders documented: Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale orally via nebulizer every 8 hours for shortness of breath Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. Rinse mouth with water after use, then…
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 · D2025-05-08 · 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 observations, record reviews and interviews, the facility failed to meet nutritional needs for 1 of 8 sampled residents, as evidenced by not providing all the food items on Resident #56 meal ticket. The findings included: Record review revealed Resident #56 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15 scale, indicating no cognitive impairment. A physician order dated 02/20/25, documented that Resident #56 is on a regular diet. During an interview on 05/07/25 at 11:55 AM, when asked how your evening was, Resident #56 revealed a picture of her dinner tray from 05/06/25, which consisted of mashed potato, green peas, sliced bread and no protein. Resident #56 stated When the tray was brought to me and it was being set up, the staff stated that's all you got. When asked if she requested something else Resident #56 stated, I asked the nurse for a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop care plans for the use of bed rails for 3 of 3 residents reviewed for bed rails, Residents #27, 56 and 62. The findings included: The facility's policy 'Side rails/Bed Rails' effective date 04/01/23, documented: General Information: 4. If therapist determined that one or two half rails enhance bed mobility and/or facilitate independent transfers from bed. These rails will be care planned for resident use. 6. M.D. order will be obtained for all side rail use. 1). Resident #27 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Significant Change Minimum Data Set (MDS), Resident #27 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented that the resident had no impairments to upper and lower extremities and was able to roll from left to right in the bed. Resident #27's diagnoses at the time of the assessment included:…
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 before2024-01-25 · 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, interview, and record review, the facility failed to maintain a resident's highest practicable level of mobility for 1 of 3 residents reviewed for activities of daily living (Resident #32). The findings included: A review of the facility's policy Nursing- Activities of Daily Living (ADLs), dated 04/01/2022, documented: The purpose was to ensure all residents needs are met in a manner that promotes their quality of life and preferences. The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility shall provide care and services for the following activities of daily living as needed based on the individual care plan of each resident: a. Hygiene- bathing, dressing, grooming, and oral care, b. Mobility- transfer and ambulation, including walking, c. Toileting d. Dining- eating including meals and snacks, e. Communication including speech, language and other functional…
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 before2024-01-25 · 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 observation and interview, the facility failed to administer oxygen as ordered for 1 of 2 residents reviewed for respiratory therapy (Resident #32). The findings included: A review of the facility's policy Nursing- Oxygen Administration, dated 04/01/22, documented the purpose of this procedure is to provide guidelines for safe oxygen administration. The following equipment and supplies will be necessary when performing this procedure: 1. portable oxygen cylinder 2. nasal cannula, nasal catheter, or mask as ordered 3. humidifier bottle. Resident #32 was observed in bed on 01/24/24 at 11:30 AM. The resident stated he was receiving oxygen through his nose, and his nose gets congested. The resident stated he complained about it and had received some medication for it in the past. A review of the resident's oxygen revealed the resident was receiving 3 liters/minute of oxygen via a nasal cannula. Further observation revealed there was no humidifier bottle (which provides moisture) attached to the oxygen. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 trauma informed care in a manner to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for behavior, Resident #36. The findings included: Resident #36 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #36 had a Brief Interview for Mental Status score of 15, indicating that the resident was cognitively intact. Resident #36's diagnoses at the time of the MDS included: Cerebral Palsy, Quadriplegia, Anxiety disorder, Schizophrenia, Post-Traumatic Stress Disorder (PTSD), Spondylopathy of Lumbosacral Region, History of UTI, Lymphocytopenia, Hereditary and Idiopathic Neuropathy. A review of the resident's Electronic Health Record revealed that the resident did not have a care plan for PTSD. During an interview with Resident #36, on 01/23/24 at 9:00 AM, when asked about the diagnosis of PTSD,…
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 · D2024-01-25 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 correct use of side rails, assess the residents for risk of entrapment from side rails, failed to obtain informed consent prior to use of side rails and failed to conduct regular maintenance checks on side rails for 3 of 3 residents reviewed for side rails, Residents #27, 56 and 62. The findings included: The facility's policy, 'Siderails/Bedrails', effective date 04/01/23, documented: 8. All side rails in use whether or not they are restraints must be carefully assessed for risk of entrapment. The maintenance department upon placement of the side rails wil complete a bed system audit to ensure proper placement of side rails. 9. The maintenance department will also complete a bed system audit any time a side rail is added or removed from a bed and whenever a mattress is changed or bolster/wedge is added or removed. 10. The maintenance department will also complete a bed system audit bi-annually of all beds in the facility to ensure…
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 · D2024-01-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to correctly verify the physician's order related to contact isolation for 1 of 1 resident reviewed for transmission-based precautions, Resident #62; and the facility failed to maintain the laundry room in a clean and sanitory manner. The findings included: 1. The facility's policy titled, Isolation- initiating Transmission Based Precautions with an effective date of 4/01/22,has General guidelines relating to requirements for implementing and maintaining Transmission Based precautions. Item 5, has the following statement: When Transmission- Base Precautions are implemented, the Infection Preventionist (or designee) shall: . There is a list of requirements to be implemented. This list includes the following: a. Ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. b. Post appropriate notice on the room entrance door and on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-29 · 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, interview, record review, and policy review the facility failed to ensure all residents were supervised to prevent elopement from the facility for 1 of 2 residents reviewed for elopement (Resident #2). The findings included: A review of the facility policy titled Nursing - Elopement Prevention defines an elopement as, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A review of Resident #2's record revealed the resident was admitted to the facility on [DATE] after being struck on his bicycle by a motor vehicle resulting in several traumatic injuries including facial fractures, rib fractures, respiratory injuries requiring a tracheostomy (trach) placement for ventilator assisted breathing and a feeding tube for nutrition due to dysphagia (difficulty swallowing). The resident was placed in this facility for rehabilitation purposes after being stabilized at 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 · Fcited before2022-09-15 · 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, interview and record review, the facility failed to provide foods prepared, served and stored in a manner to prevent the potential growth of pathogens that cause foodborne illness and in accordance with professional standards for food safety. The findings included: 1) During the initial kitchen tour, on 09/12/22 at 8:15 AM, accompanied by the Certified Dietary Manager, the following was observed. a. The blade of he the can opener was encrusted with food residues. b. There was an accumulation of dust on the air conditioning vents over the food preparation area. c. There was an accumulation of dust on the sprinklers for the fire suppression system over the food preparation area. d. There was an accumulation of food residue on the gasket inside of the door to the walk in cooler. e. The waste dumpster that was located behind the facility was left open and was noted to be dirty. f. Brooms that were kept in the Janitor's closet were stored on the floor. During an interview, on 09/15/22 at 2:38 PM with the Certified Dietary Manager, she was informed of the findings…
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 before2022-09-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. The findings included: Upon entering the facility, on 09/12/22 at 7:30 AM, there was an odor indicative of mold throughout the common areas of the facility. During an interview, on 09/12/22 at 10:27 AM, the concern of the mold like odor was brought to the attention of the Maintenance Director. It was noted that the air conditioning vents had an accumulation of dust and a black mold like substance, as did the vents over the nurse's stations. The ceiling tiles that were adjacent to the vents over the nurse's station were stained in a manner indicative of the tiles absorbing water. There was an area of the ceiling in the common area that appeared as though mold was painted over. The Maintenance Director stated that the facility would have an outside company come to the facility to clean the vents and dust and mold like substance. Upon returning to the facility, on 09/13/22 at 8:00 AM, the odor…
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 · E2022-09-15 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to monitor residents' weights per physician orders and facility policies and procedures for 8 of 10 residents reviewed for nutrition (Residents #29, 34, 27, 47, 20, 38, 5, 258). The findings included: The facility's policy 'Weighing the Resident' documented: Residents will be weighed unless ordered otherwise by the physician * Admission/re-admission x 3 days * Weekly x 4 weeks * Monthly thereafter * As needed Procedure: * Weights will be completed as indicated and documented in the clinical record. * Identify the Resident. * Review prior month's weight and the scale that was used. Use same scale if possible. * When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. * Record weight and alert nurse to any significant change. * Nurse to notify the physician of any significant weight change. * Consult with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-15 · 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 facility policy, record review, and interview, the facility failed to monitor and report lab results for 2 of 2 residents reviewed for Urinary Tract Infection (Residents #8 and #13). The findings included: A urinalysis is a test of the urine used to detect and manage disorders such as urinary tract infection, kidney disease and diabetes. A urine culture is a test to detect bacteria and organisms in the urine and which antibiotics will best treat it. Facility Policy titled Lab and Diagnostic Test Results- Clinical Protocol documents, The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. A nurse will review all results. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record. 1). On 09/12/22 at 12:10 PM Resident #8 stated she has had a urinary tract infection for a long time, and they do not seem to be doing anything…
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 before2022-09-15 · 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 facility policy, observation, interview, and record review, the facility failed to ensure the environment was free from accident hazard and potential for injury. This requirement was not met due to hot water temperatures being above recommended range. This failure affected 4 of 8 residents sampled for bathroom water temperatures (#29, #41, #9, #38). The findings include: Facility Policy titled Water Temperature Monitoring review date 01/18/22 documented, It is the policy of Beach Breeze Rehab and Care Center to ensure the hot water temperature is maintained between 105 degrees - 115 degrees. (Fahrenheit) On 09/12/22 at 10:00 AM the surveyor noted water in the restroom to be uncomfortably hot. A TEL-[NAME] handheld thermometer was calibrated, and the following bathroom hot water temperatures were noted: room [ROOM NUMBER] and room [ROOM NUMBER]= 126 degrees Fahrenheit, room [ROOM NUMBER]= 124 degrees Fahrenheit, room [ROOM NUMBER]= 120 degrees Fahrenheit, room [ROOM NUMBER] and room [ROOM NUMBER]= 118…
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 before2022-09-15 · 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 observations, interviews and record review, the facility failed to provide enteral feeding as ordered for 1 of 6 residents reviewed for tube feeding, Resident #34. The findings included: Resident #34 was admitted to the facility on [DATE]. According to a Medicare 5-Day MDS, dated [DATE], Resident #34 was not assessed for cognition due to 'resident is rarely/never understood' and was completely dependent upon staff for all Activities of Daily Living (ADLs). Resident #34's diagnoses at the time of the assessment included: Aphasia following cerebrovascular disease, Anemia, Hypertension, Seizure disorder, Depression, Psychotic disorder, Acute respiratory failure with hypoxia, Morbid (severe) obesity, Abnormal posture, Lack of Coordination, Muscle weakness, Mild cognitive impairment, Tracheostomy complication. The MDS documented that the resident had swallowing disorders that included: 'Loss of liquids/solids from mouth when eating or drinking'. 'Holding food in mouth/cheeks or residual food in mouth after…
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 · D2022-09-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 facility policy, record review and interview, the facility failed to maintain accurate resident records. This failure affected 1 of 15 sampled residents (Resident #8). The findings include: Facility Policy titled Physician's Orders dated 04/01/22 documents, It is the policy to write physicians' orders to establish a plan of care to follow for the care of the patient. Purpose: To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner. Vital signs definition is clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions. Record review on 09/12/22 for Resident #8 revealed an active Physicians Order for Vital Signs every Friday initiated 02/13/22. Review of Blood Pressure Summary Record for Resident #8 documented a Blood Pressure of 124/69 on 05/05/2022 with no further entries. Review of Pulse Summary Record for Resident #8 documented a Pulse of 80 on 05/05/2022 with no further entries. Review of 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.
- No harm found · B2025-05-08 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to review and update the Facility Assessment accurately and in a timely manner. The findings included: During the entrance conference for the annual recertification survey, on 05/05/25 at 8:41 AM, with the Administrator, the Surveyor requested a copy of the Facility Assessment. The Administrator retrieved a copy of the assessment from a binder and handed it to the Surveyor and confirmed that it was the most recent copy. The Facility Assessment provided by the Administrator documented: Requirement: Nursing facilities will conduct, document, and annually review a facility-wide assessment which includes their resident population and the resources the facility needs to care for their residents. Guidelines for conducting the assessment: 3. The facility must review and update this assessment annually or whenever there is, or the facility plans for any change that would require a modification to any part of this assessment. For example, the facility decides to admit residents with care needs who were previously not admitted , such…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to EXCELSIOR CARE GROUP — 33 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 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 4 of 5 | 2.3 | +1.7 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 32 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PALM SPRINGS SNF OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/03/2021 |
| SUNSHINE SNF GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 09/30/2021 |
| LEIFER, JOEL | Individual | CORPORATE OFFICER | — | since 04/01/2022 |
| DAUPHIN, ROCHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/22/2025 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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. 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 105492. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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.