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Darcy Hall Of Life Care

2170 Palm Beach Lakes Blvd, West Palm Beach, FL 33409 · For profit - Limited Liability company · 220 certified beds · (561) 683-3333 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse2 immediate-jeopardy citations$30,924 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $30,924 in federal fines (most recent 2025-09-05)
  • 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)
  • about 18% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
560 Village Blvd Ste 315 · (561) 616-9988 · Call to confirm hours
Pharmacy
Walgreens0.1 mi
2200 Palm Beach Lakes Blvd · (561) 615-0415 · Call to confirm hours
Grocery
580 Village Blvd Ste 330 · (800) 837-2881 · Call to confirm hours
Park
414 Erie Pl · (561) 804-4900 · Typically dawn to dusk

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 improved from 1 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.7%8.7%15.4%better
Long-stay residents who lose too much weight9.5%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%0.7%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.4%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.7%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.0%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.5%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control3.9%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 table11.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication9.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.8%94.7%79.4%better
Short-stay residents rehospitalized after admission37.3%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.1%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.662.131.67typical
Long-stay outpatient ER visits per 1,000 resident days1.281.151.80better

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

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

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

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

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

36.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.2%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
68.3%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 68.3% 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 41 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 0.12 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.2%CMS range 23.6–52.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.1–15.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge63.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 3.8–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.87
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.44
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.62
RN hoursweekends
27.2%
Total nursing turnover
45.3%
RN turnover

How full it usually is: this home is certified for 220 beds and averages 181.5 residents a day — about 82% occupied, or roughly 38 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 4.09 on weekdays — 14% thinner on weekends. RN hours go from 0.97 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%.

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

9
deficiencies at the latest standard inspection (2025-01-30)
6
at the previous standard inspection (2023-10-05)

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.

ABCDEFGHIJKL

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

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interviews, observations, record and policy review, the facility failed to protect the resident's right to be free from neglect by failing to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM, and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F689.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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, record and policy review, the facility failed to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F600.The findings included:A review of the facility's policy titled, Missing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an effective infection prevention and control program to help prevent the development and transmission of the communicable disease scabies, as evidenced by the failure to ensure documented evidence of the provision of ivermectin, a medication to treat scabies, and ensure dermatological appointment for Resident #1; failure to initiate timely contact precautions for 3 of 11 sampled residents (Residents #8, #5, and #2); failure to ensure an effective Infection Control Surveillance plan as evidenced by the failure to log 7 of 10 sampled residents who presented with a rash and were reported to the State Agency in October 2025 (Residents #1, #7, #9, #10, #11, #12, and #13), and 2 of 2 sampled residents in November 2025 (Residents #2 and # 8); failure to ensure appropriate housekeeping and laundry services for residents affected with and or treated for scabies for 1 of 6 units affected (West Unit); and failure to ensure staff education in November 2025…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 and interview, the facility failed to promote healing of a facility acquired pressure ulcer for 1 of 3 sampled residents (Resident #1).The findings included: Record review revealed Resident #1 was initially admitted to the facility on [DATE], with multiple readmissions, with a diagnosis that included Dementia. A review of a comprehensive assessment dated [DATE] documented that the resident had severe cognitive impairment and required total assistance with all activities of daily living. The assessment further documented Resident #1 had weight loss, two stage 3 pressure ulcers and was always incontinent of bladder and bowel.Record review revealed Resident #1 was care planned for at risk for break in skin integrity, dated 10/22/19. Interventions included clean and dry skin after each incontinent episode, turn and reposition frequently, and a low air loss mattress.Record review revealed Resident #1 was care planned for a left buttock and sacral pressure ulcer, dated 01/11/26. Interventions…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and clinical and administrative record review, the facility failed to ensure the necessary care and services were provided for 1 of 2 sampled residents, (Resident # 2), reviewed for medical appointments and/or medical procedures, as evidenced by the facility's failure to provide the necessary nursing supervision during transport to medical procedure for an incapacitated resident; and failed to ensure the health care surrogate was fully informed and adhered to preferences voiced or informed when changes are made prior to implementation. The findings included: Review of the clinical record for Resident #2, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular Accident (CVA), Hypertension (HTN), Diabetes Mellitus (DM), Dysphagia following cerebral infarction, Epilepsy and expressive aphasia. Review of the Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) score…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor a resident's choices related to showers for 1 of 3 sampled residents reviewed for choices (Resident #16). The findings included: A review of Resident #16's medical records revealed she was admitted to the facility on [DATE], with diagnoses to include Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following a Cerebral Infarction (stroke), affecting the right dominant side, Muscle Weakness and Diabetes. A review of Resident #16's Quarterly MDS (Minimum Data Set) assessment documented her BIMS (Brief Interview for Mental Status) score as a 9, indicating moderate impaired cognition. The assessment (Section GG) documented Resident #16 is dependent on showers/bathing and she has upper and lower impairment on one side of her body. A review of care plans documented Resident #16 requires assistance by staff with showering and bathing. During an interview on 01/28/25 at 12:31 PM, Resident #16 was asked if she…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to document an accurate Advance Directive care plan for 1 of 39 sampled records reviewed (Resident #121). The findings concluded: Record review revealed Resident #121 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent for activities of daily living (ADL). The assessment further documented the resident was receiving hospice services. A review of Resident #121's care plan revealed a care plan dated [DATE] that documented the resident had an Advance Directive for CPR (Cardiopulmonary Resuscitation) and was a full code (a medical term that indicates a resident's preference for resuscitation and all life saving measures during a medical emergency). A review of Resident #121's orders revealed an order dated [DATE] for DNR (Do Not Resuscitate). Further review of Resident #121's records revealed a State of Florida DNR order form dated [DATE]. An interview was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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 provide proper care and treatment, as evidenced by not providing a communication board, to maintain the resident's communication abilities for 1 of 1 sampled resident, Resident #75, reviewed for Activities of Daily Living (ADLs). The findings included: Record review revealed Resident #75 was admitted to the facility on [DATE]. The resident was admitted to Hospice Services on 08/02/24 with diagnoses that included Anxiety Disorder, Major Depressive Disorder, Persistent Mood Disorder, Panic Disorder, and Dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Resident #75 was dependent on assistance with activities of daily living which included care for incontinence. Review of Resident #75's care plans noted that she had a communication problem. The intervention for the communication problem since 05/21/23…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Review of the record revealed Resident #45 was admitted to the facility on [DATE]. Review of the current physician orders revealed the resident was prescribed two medications for high blood pressure, to include Amlodipine 2.5 mg (milligrams) once daily, and Lisinopril 10 mg once daily. Resident #45 was also prescribed Carvedilol 6.25 mg twice daily for Coronary Artery Disease. Further review of the orders lacked any type of blood pressure or heart rate parameters for holding any of the three medications. Review of the current January 2025 Medication Administration Record (MAR) revealed all three medications were held on 01/06/25 for the 9 AM dose because of the resident's heart rate of 55 beats per minute. The Carvedilol was held on 01/17/25 for the 5 PM dose, with a corresponding progress note that documented, hold per BP (blood pressure) value. The documented blood pressure for that administration was 124/59. Review of the December 2024 MAR revealed all three of the above mentioned medications were held on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to discard narcotics/controlled medications in a timely manner for 2 of 8 sampled residents (Resident #64 and #124); and failed to reconcile narcotics, as evidenced by not documenting the medication administration on the Medication Administration Record (MAR) for 2 of 8 sampled residents (Resident #124 and #263). The findings included: A review of the facility's policy titled, Administration of Medication, last reviewed on 09/16/24, documented: Medication administration should be documented timely following the administration to the resident. 1. Record review revealed Resident #64 was admitted to the facility on [DATE]. A medication storage observation was conducted with Staff A, a Licensed Practical Nurse, of the Northwest medication cart on 01/29/25 at 4:00 PM. The observation revealed 6 medication packs of Lorazepam (anti-anxiety medication) for Resident #64 as follows: a. A medication pack of 3 pills of Lorazepam 0.5 mg. The pack was received 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure safe medication storage for 1 of 8 medications carts (D Unit) and 1 of 3 treatment carts (West Unit), as evidenced by these carts being left unlocked and unattended, with independently ambulatory residents noted. The findings included: 1) On 01/27/25 at 9:54 AM, the medication cart on the D Unit was observed unattended and the push in lock was not engaged. The lock was easily pulled out and the medication cart drawers were easily opened. The medication cart was filled with medications for the 22 residents residing on the D Unit along with the generic stock medications. While awaiting the arrival of a staff member, Resident #100 was observed independently ambulating in the hallway in front of the medication cart. There were no staff observed in the hallway of the D Unit. A few minutes later the Assistant Director of Nursing (ADON) came to the medication cart and agreed with the concern of the unlocked medication cart. On 01/27/25 at 9:58 AM, Staff A, Licensed Practical Nurse (LPN), returned to the medication cart and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide food in a puree form to meet the individual needs of residents for 3 of 17sampled residents (Resident #48, Resident #46, Resident #65) on a medically ordered pureed diet. The findings include: Review of the facility's Life Care Centers of America Policy, reviewed on 5/01/2024, documented the Pureed diet consists of foods that are easy to swallow because they are blended, whipped, or mashed until they are pudding-like texture. All foods on this diet should be smooth and free of lumps. (National Dysphagia Definition). The purpose of the pureed diet is designed to minimize the amount of chewing required and to facilitate the ease of swallowing food. This diet is designed for residents who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. 1). Record review revealed Resident #46's active diagnoses included Alzheimer's disease, and Dementia. A review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], documented…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-01-30 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 accommodate a resident's food preferences and offer an alternative food option after the resident refused a meal, for 1 of 8 sampled residents reviewed for nutrition (Resident #18). The findings include: Record review revealed Resident #18 was admitted to the facility on [DATE]. Her diagnoses included Protein Calorie Malnutrition, Malignant Neoplasm of Breast and Anxiety Disorder. Review of Resident #18's Minimum Data Set quarterly assessment dated [DATE], documented the resident's Brief Interview of Mental Status score was 99, which indicated the resident was unable to complete the interview. She was noted to rarely/never understand, and rarely/never be understood. A nutrition intervention listed on Resident #18's care plan last revised on 01/23/25, was to provide and serve the diet as ordered. Record review of the Resident's Nutrition Care Plan dated 1/23/25, documented Resident #18 had increased needs for nutrition due to her diagnosis…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect approximately 158 of 165 residents. The findings included: During the initial tour of the Main Kitchen on 01/27/25 at 10:13 AM, accompanied by the Food Service Director (FSD), the following was observed: 1. A personal backpack was observed on a shelf below the food preparation area. The backpack was resting on dishware. 2. In the dry storage room, a gray plastic bin was observed with dark colored sediment on the handle of the container, on the inside of the bottom of the container, and on the handles of at least four of the scoop serving utensils. 3. The Cleveland steamer had brown/red wet residue around the perimeter of the upper steamer and the upper exterior of the lower steamer. During a subsequent interview during the tour, the FSD acknowledged the findings. A tour of the nourishment room in the [NAME] Wing was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 failed to protect a resident from repeated physical abuse for 1 of 1 sampled resident reviewed for abuse (Resident #1). The findings included: A review of the Facility's policy Abuse Prevention, issued on 10/04/22 and reviewed on 07/18/23, Documented: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Procedure #4 documented: To identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors, which might lead to conflict or neglect, such as verbally aggressive behavior and physically aggressive behavior. A review of the facility's abuse log revealed a resident (Resident #2) to resident (Resident #1) substantiated allegation specifically, of abuse on 10/14/23 and 10/26/23. Resident #1 was assaulted by Resident #2 on 10/14/23. Resident #2 was transferred to the hospital for unrelated concerns on 10/14/23. Resident #2 returned 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-05 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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

    Based on observation, interview, and record review, the facility's approved menu was not followed for 16 residents (includes sampled Resident #16, #20, #54, and #72) with physician ordered Pureed Diet for, 17 residents (includes sampled Resident #70) with physician ordered Easy To Chew Diet, and 14 residents (includes sampled Resident #28, #59, and #125). The findings included: 1) During the review of the approved facility menu to be served for the lunch meal on 10/02/23, the following were noted: Regular Diet: Kielbasa (4 ounce edible portion) Regular Diet: Potatoes O'Brien, Fruit Crisp Easy To Chew Diet: Ground Pork Roast, Soft Potatoes O'Brien, Soft Fruit Crisp Mechanically Altered Diet: Ground Pork Roast, Soft Potatoes O'Brien, Pureed fruit Crisp Pureed Diet: Pureed Pork Roast, Pureed , Soft Potatoes O'Brien, Pureed fruit Crisp Regular Diet: Potatoes O'Brien Alternate Regular Diet: Chop Steak (4 ounce Edible Portion) Alternate Regular Diet Starch: Buttered Corn Alternate Easy To Chew Diet & Mechanical Altered Diet: Buttered Corn Alternate Pureed Diet: Pureed Buttered Corn 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 175 of the facility resident's. The findings included: 1) During the initial kitchen/food service observation tour conducted on 10/02/23 at 9:15 AM and accompanied with the with the Food Service Director and Regional Administrator, the following were noted: (a) Ceiling mounted air-conditioning vent and drip pan located above food preparation surfaces and the 3-compartment sink was noted to be soiled and full of condensation. Further observation noted that the contaminated condensation was dripping down on food preparation counters, 3-compartment sink area, and the floor area under the vent. It was discussed with the Food Service Manager (FSD) that there was a potential of contamination from the dripping condensation. The surveyor requested that staff not have access to the areas surrounding the vent and drip pan until the issues was resolved. (b) The commercial plate warmer…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the shower binder, the facility failed to honor resident's choice for receiving and scheduling of showers for 1 of 2 sampled residents (Resident #117). The findings included: Record review revealed Resident #117 was admitted to the facility on [DATE] with pertinent diagnoses of Dementia with behavioral disturbance, and Malignant Neoplasm of Colon. Review of Resident #117's Annual Minimal Data Set (MDS) assessment dated [DATE], section F, revealed that it is very important for the resident to choose between a tub bath and a shower. The MDS also documented Resident #117 requires a one-person physical assist for bathing and for Activities of Daily Living (ADLs). During the initial tour of the facility conducted on Monday, 10/02/23 at 10:12 AM, Resident #117 was observed in his wheelchair waiting in the hallway. When the surveyor greeted Resident #117, he stated I want a shower. The surveyor returned to the unit at 12:35 PM, Resident #117 was still…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and policy review, the facility failed to dispose of expired medications in 1 of 5 medications carts (Southwest unit), affecting Resident #30, and in 1 of 2 medication storage rooms (Southwest unit); and failed to ensure the proper route of administration in the labeling of medications for 1 of 7 sampled residents observed during medication administration observations (Resident #32). The findings included: Review of the facility's policy title Storage and Expiration Dating of Medication, Biologicals, dated 12/01/07, revealed the following: Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). Policy 8.2: Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 adaptive eating equipment as per Occupational Therapy (OT) assessment and orders for 3 of 8 sampled residents reviewed for nutrition (Resident #70, #41 and #164). The findings included: 1) Resident #41 was admitted to the facility on [DATE] with diagnoses which included Dysphasia, Alzheimer's, Dementia, Depression, Anxiety, Gastroesophageal Reflux Disease, Hypothyroidism, and Protein Calorie Malnutrition. During record review for Resident #41, an order for Adaptive Equipment, dated 04/11/23, required dycem under plate, foam handled built-up utensils, 2 handled cup with lid and straw, and divided plate for all meals. Resident #41's OT Assessment Discharge summary, dated [DATE], recommended for Feeding: 3 compartment divided plate, dycem under the plate, foam built up utensils and 2 handled cup with lid and straw. A weight change note dated 07/07/23 and a dietary note, dated 07/15/23, both documented that Resident #41 was to be…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0914 — isolated
    Provide bedrooms that don't allow residents to see each other when privacy is 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 it was determined that the facility failed to provide ceiling suspended curtains which provides total visual privacy for 3 of 3 sampled residents (Resident #16, #20 and #72), reviewed for privacy. During the screening of facility residents on 10/02/23 at 10:30 AM, it was noted that Resident #16, #20, and #72 occupied a room together. Further observation noted that there were no privacy curtains between the beds of beds of Resident #16 and #20, and only a small curtain between the beds of Residents #16 and #72. Further observation noted that the hooks were on the ceiling tracks without the curtains present and there was no privacy between all three resident beds. It was also noted that the 3 resident's had some cognition issues and required total care. On 10/03/23 at 9 AM, a second observation was made of the room and it was again noted that there were no privacy curtains present in the room and indicating the facility was not providing privacy for the residents…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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, it was determined, the facility staff failed to report and thoroughly investigate allegations of neglect for 1 of 2 sampled residents (Resident #2). The findings included: Facility policy titled Abuse Reporting and Response - No Crime Suspected dated 10/04/22 documents The facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of residents property and report the results of all investigations to the proper authorities within prescribed timeframe. Abuse Identification: Neglect: is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review conducted on 09/19/23 revealed Resident #2 was admitted to the facility on [DATE] for rehabilitation and was transferred to the hospital on [DATE] for possible reaction…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to identify resident to resident abuse and failed to report the abuse incident involving 2 of 2 sampled residents, Residents #139 and #78. The findings include Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed 05/15/2020 and revised 08/10/2021 specifies the facility must: Identify, correct and intervene in in situations in which abuse is more likely to occur. It also affirms All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin; All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative; All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin will be immediately reported to the administrator and or director of nursing; The person(s) observing an incident of resident abuse or suspecting resident abuse will immediately report…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to follow the care plan in place to prevent resident to resident abuse involving 2 of 2 sampled residents, Residents #78 and #139. The findings include On 06/06/2022 at approximately 11:30 AM, surveyor was present in the dining room during activities. Staff L, a CNA (certified nursing assistant) and Staff M, an activity assistant, were also present. Resident #78 was seated at the main table in her wheelchair next to Resident #139. Resident #78 was somewhat agitated and verbally lashing out in general, although her words were nonsensical. Resident #78 suddenly grabbed Resident #139's right wrist and the lower part of her hand and was squeezing it tightly. Resident #139 was grimacing, and other residents began yelling for help. Staff M was able to separate the two residents. Resident #139 was visibly upset and rubbing her arm. She did not attempt to strike back or retaliate in any way. Staff M then moved Resident #78 to the other side of Staff M's space so she was not sitting next to any other residents. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3). Facility Policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 04/19/2022 states A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; Measures to maintain and improve the resident's tissue tolerance are implemented in the plan of care. Record review revealed Resident #89 was admitted to the facility on [DATE], with diagnoses that include, cerebral vascular accident (Stroke) with right hand contracture (A condition of shortening and hardening of muscles and other tissues often leading to deformity and rigidity of joints), and heart disease. The facility resident assessment documented that Resident #89 is severely cognitively impaired and totally dependent on staff for all activities of daily living. On 06/08/2022 at 10:40 AM during a wound care observation with Staff Z, a RN (Registered Nurse), 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide activities listed, according to the scheduled activities calendar for 2 of 3 sampled residents, reviewed for activities (Residents #25 and #33). The findings included: Review of the facility's policy titled Therapeutic Activities Program, revised on 04/01/22, reveals The facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well -being and independence. 1. On 06/07/22 at 9:03 AM Resident #25 was interviewed andasked if he attends activities. He stated that there are no activities for him here (facility). He wishes they had activities for people that are alert. Resident #25 has diagnoses that include End Stage Renal Disease, Spinal Stenosis, and Muscle Weakness. His Brief Interview for Mental Status (BIMS) score is 15, per…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the accuracy of the electronic medication administration records (eMAR) for 4 of 5 sampled residents reviewed for unnecessary medications (Residents #115, #116, #127, and #371). The findings included: Facility policy regarding Nursing Documentation (reviewed 05/05/20 and revised 05/07/21) documents, This facility will ensure nursing documentation is consistent with professional standards practice, the state nurse act, and any state laws governing the scope of nursing practice. Paragraph #3 under INTRODUCTION, it states: Federal regulations require that long-term care facilities maintain clinical record for each resident and that these records contain sufficient information to identify resident. These records must also be complete, accurate, readily accessible, and systematically organized and must provide documentation of the resident's assessments and the care plan and services provided. Under IMPLEMENTATION, bullet #12 states: Document…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-06-09 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to issue CMS Form 10055 (SNFABN) for 2 of 3 sampled residents, whose discharge from Medicare Part A was initiated by the facility, whose benefit days were not exhausted, and who remained in the facility (Resident #41 and Resident #171). The findings included: A) A review of Resident #41's Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) documentation showed that Resident #41's Medicare Part A start date was 03/14/22, and the last covered day for Medicare Part A was 04/02/22. The facility initiated the resident's discharge from Part A when the resident's benefit days were not exhausted, and the resident remained in the facility. A copy of CMS Form 10123 (NOMNC) was provided to the resident/family on 03/30/22. The CMS Form 10055 (SNF ABN) should have also been provided to the resident/family, as per regulatory requirement, but it was not. B) A review of Resident #171's Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) documentation showed that Resident #171's Medicare Part A start date was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$30,924 in federal fines across 1 penalty.

  • $30,924 — penalty dated 2025-09-05

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 LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 5 of 53.3+1.7 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV 2 of 5Life Care Center Of TullahomaTullahoma, TN

Showing 40 of 193; 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 / managerTypeRoleSince
PRESTON, FORRESTIndividualDIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2006
KAPELOS, JOANNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/26/2023
PRESTON, AARONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
STEPHENS, KENDRAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/25/2025
HENRY, TERRYIndividualCORPORATE DIRECTORsince 07/01/2006
CROSS, CINDYIndividualCORPORATE OFFICERsince 07/01/2006
THURMOND, JOANIndividualCORPORATE OFFICERsince 07/01/2006
DARCY HALL MEDICAL INVESTORS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/14/2006
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/07/2006
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
LAY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/24/2017
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/27/2024
RODRIGUEZ, YANITZAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/25/2025
SWANKER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/07/2006

CMS files one row per role, so the 25 rows in the source record cover these 15 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.

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.

$16.6M
Net patient revenuemost recent cost report
+0.7%
Operating marginrevenue minus expenses
$3.0M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 3%Other / private 12%

About 85% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$261per resident / day
operating cost
$7,940per month
≈ monthly operating cost
$263per day
avg. revenue, all payers

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

What families pay in FL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105516. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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