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Lourdes-Noreen McKeen Residence For Geriatric Care

315 S Flagler Dr, West Palm Beach, FL 33401 · Non profit - Corporation · 132 certified beds · (561) 655-8544 Medicare & Medicaid certified

Call the home — (561) 655-8544 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 30 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • 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-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own 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
101 N Clematis St Ste 110 · (561) 365-3000 · Call to confirm hours
Pharmacy
400 Clematis St · (561) 273-0022 · Call to confirm hours
Grocery
244 S Olive Ave · (561) 249-1353 · Call to confirm hours
Park
Post Park<0.1 mi
315 S Flagler Dr · (561) 804-4900 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 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 3 to 4 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 rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.3%8.7%15.4%better
Long-stay residents who lose too much weight3.2%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.1%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.3%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 injury2.6%2.5%3.3%better
Long-stay residents whose ability to walk worsened16.3%9.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication6.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine99.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.8%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control19.4%10.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.5%94.7%79.4%better
Short-stay residents rehospitalized after admission26.5%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.4%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.022.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.631.151.80better

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.

48.9% 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 286 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
38.5%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 38.5% 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 166 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 43% 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 SNF48.9%CMS range 43.3–53.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.8–14.310.7%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 discharge38.5%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 discharge45.8%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 discharge32.5%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 identified98.1%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 setting97.5%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 discharge94.5%98.7%Oct 2024–Sep 2025CMS 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 stay0.9%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 worsened1.9%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 hospitalization9.0%CMS range 5.8–14.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

1.08
RN hours/ resident / day
0.48
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.85
RN hoursweekends
28.8%
Total nursing turnover
13.3%
RN turnover

How full it usually is: this home is certified for 132 beds and averages 126.0 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.62 hrs/resident/day on weekends vs 4.13 on weekdays — 12% thinner on weekends. RN hours go from 1.18 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% 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

14
deficiencies at the latest standard inspection (2025-09-05)
3
at the previous standard inspection (2024-05-09)

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.

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 · E2025-09-05 · tag F0880 — failed to prevent and control infections — pattern
    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 policy review, observation, interview, and record review, the facility failed to implement infection control processes to prevent the spread of infection during 1 of 3 meals observed in the 2S dining room (lunch meal on 09/04/25) as evidenced by the staff failure to perform hand hygiene between resident contact; failure to implement and or follow Enhanced Barrier Precautions (EBP) for 4 of 8 sampled residents, Resident #41 who had an open wound, Resident #133 who had an indwelling urinary catheter, Resident #48 who had an indwelling urinary catheter, and Resident #97 who had a wound; and failure to disinfect the glucometer for 1 of 2 observations, after use for Resident #2.The findings included:Review of the policy titled Hand Hygiene (Copyright 2025) documented, in part, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation…

    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 · D2025-09-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, interview, and record review, the facility failed to ensure of rendering dignified care and services for 2 of 29 sampled residents as evidenced by the voiced dislike of using a shampoo instead of an appropriate cleanser during a bath for Resident #31, and failure to treat and speak to Resident #31 and #41 in a dignified manner.The findings included:1) Review of the policy Bed Baths (Copyright 2024) documented in part, 6. Wash the resident's eyes with water only, . 7. Wash the resident's face using soap or a facial cleaner . Review of the record revealed Resident #31 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating moderate cognitive impairment. This MDS also documented the resident needed substantial to maximum assistance from staff for toileting and bathing.During an interview on 09/02/25 at 11:32 AM,…

    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 · D2025-09-05 · 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 observation, interview, and record review, the facility failed to ensure residents rights for 2 of 8 sampled residents as evidenced by the failure to ensure showers and hair washing for Resident # 12, and failure to use room shower for Resident #97.The findings included:1) Review of the record revealed that Resident #12 was admitted to the facility on [DATE] with diagnoses documented in part, Unspecified Dementia, Hemiplegia and Repeated Falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #12 had a Brief Interview for Mental Status (BIMS) score of 7 on a 0-15 scale, indicating the resident had severe cognitive impairment. Review of the Care Plan dated 01/25/23 revised on 01/22/25 revealed that Resident #12 required extensive assistance with bathing and showering, and Resident #12's daughter requested to have her mother's hair washed on shower days. An interview was conducted on 09/02/25 at 3:36 PM with Resident #12's daughter who stated that she is not sure 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the desired code status was in place for 1 out of 29 sampled residents reviewed for Advanced Directives (Resident # 1). The findings included:Review of the facility's policy titled, Advance Directives dated [DATE] included, in part, the following: Policy Interpretation and Implementation . 4. Do not resuscitate orders (DNRO) will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. 5. The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.Record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, on a scale of 0 to 15, which indicated the resident 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
  • Potential for harm · Dcited before2025-09-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 review, and interviews, the facility failed to provide dining services to 1 of 3 sampled residents in the 4N and 2S dining rooms, as evidence by failure to provide supervision for Resident #50 and additional residents observed during mealtime.The findings included:1) Record review revealed that Resident #50 was readmitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 08 on a 0-15, scale indicating moderate cognitive impairment. Review of the medical diagnosis documented a history of dysphagia (difficulty swallowing), malnutrition. An observation was conducted on 09/03/25 at 9:02 AM in the 4North dining room, Resident #50 and six other residents were observed in the dining room alone. Resident #50 was sitting at the table alone with a sippy cup with a red colored drink, of thickened consistency, with a straw inside of it. The resident was coughing profusely nonstop. Staff O, Licensed Practical…

    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 before2025-09-05 · 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

    Based on facility policy, observations, record reviews and interviews, the facility failed to provide wound care and services for 1 of 2 sampled residents as evidenced by failure to ensure Resident #85 had treatment ordered for a wound to his forehead.The findings included:Review of the facility policy titled Wound and Skin Care-Wound Assessment and Documentation, dated reviewed 06/13/24, documented in part Policy Explanation and Compliance Guidelines: 1. The purpose of wound assessment is the foundation of the care plan, assists in determining the cause (etiology) of the wound, essential tracking of the progress or deterioration of the wound, determining the effectiveness of the treatment plan, obtaining reimbursement, preventing litigation and for compliance. Record review revealed that Resident #85 was admitted to the facility of 07/17/24. Review of the annual comprehensive assessment documented a Brief Interview Mental Status (BIMS) score of 15 on 0-15 scale, indicating no cognitive impairment.During an observation conducted on 09/02/25 at 11:19 AM, Resident #85 was noted with a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, interview, and record review, the facility failed to ensure the provision of nutritional supplements as per physician order for 1 of 3 sampled residents, Resident #133.The findings included:Review of the policy Nutritional and dietary Supplements (Copyright 2025) documented in part, Nutritional Supplements refer to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, . 2. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs.Review of the record revealed Resident #133 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating severe cognitive impairment for Resident #133.Review of the current physician orders documented Resident #133 was to receive a Magic Cup and a Mighty Shake as of 08/29/25, both…

    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 before2025-09-05 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the administration of nutrition via a tube as per physician order for 1 of 3 sampled residents, Resident #102.The findings included:Review of the record revealed Resident #102 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented Resident #102 had a Brief Interview for Mental Status (BIMS) score of 9, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This same MDS also documented Resident #102 had coughing and swallowing difficulties while eating and received 50% or more of his nutrition via a tube.Review of the current physician order documented as of 08/21/25 Resident #102 was to receive Jevity 1.5 Calorie (a specific brand of nutritional feeding administered via a tube) at 70 ml (milliliters) per hour for 20 hours. This order specified to start the feeding via tube at 1 PM daily and to stop it the following day at 9 AM, to ensure 1400…

    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 · D2025-09-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, observation and interview, the facility failed to ensure oxygen care and services for 3 of 4 sampled residents as evidenced by the failure to change and date oxygen tubing and clean filters for Resident #6, Resident #9 and Resident #88.The findings included:Review of the policy titled, Oxygen Safety-Nursing Service, dated 04/21/23 does not include any policy on the frequency of changing and dating oxygen tubing, and the procedure for cleaning the oxygen filter. 1) Review of the record revealed that Resident #6 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses in part of Cerebral Infarction, Acute Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Physician Orders for Resident #6 revealed the following orders dated 04/02/25, Oxygen 2 Liters via nasal canula continuously every shift related to Acute Respiratory Failure with Hypoxia, and to change, label, and bag all tubing and masks for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · 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 observations, interviews, and record review, the facility failed to remove expired inventory from the medication cart and the medication room on 4N for 2 out of 2 medication carts and for 1 of 2 medication rooms reviewed. The facility failed to ensure narcotic reconciliation on 2S for 1 of 2 medication carts reviewed. The findings included:1. Review of the facility's policy titled, Disposal of Medication and Medication Related Supplies, dated [DATE], included the following: Procedure: B. When a dose of a controlled medication is removed from the container .or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record book on the line representing the dose. On [DATE] at 11:20 AM a review of the medication cart contents on 4N was conducted with another surveyor and with Staff O, LPN (Licensed Practical Nurse). It was observed that several medications in the medication cart were…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-09-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 2 of 2 sampled residents, as evidenced by a medication error rate of 15.38% with 26 opportunities due to failure to ensure that Resident #65 received medications ordered and was available for her, failure to ensure Resident#2 received medications as ordered. The findings included:1) An observation was conducted on 09/03/25 at 9:20 AM, Staff O, Licensed Practical Nurse (LPN) was observed administering medications for Resident #65. As she begun to prepare the medications, she stated, I do not have the Mag Ox or Calcium for the resident, so I will not give them to her. As the nurse prepared each medication the name was verified on the label of the medications. Staff O, LPN was asked how many pills were in the medicine cup she stated 10. She also had an inhaler. Staff O, LPN walked into the resident's room and the resident was on the phone. She asked the resident if she wanted her to come back. The resident shook her head yes. She left the room. An observation 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store medication properly for 1 of 29 sampled residents, as evidenced by medication being left at the bedside for Resident #32. The findings included:Record review revealed Resident #32 was admitted to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, on a 0 to 15 scale, indicating moderate cognitive impairment.An observation was conducted on 09/02/25 at 11:10 AM revealed, a bottle of prescription medication was noted on Resident #32's nightstand (photographic evidence obtained).An observation conducted on 09/03/2025 at 11:26 AM, revealed a bottle of prescription topical medication was observed on Resident #32's nightstand.Review of the assessments for Resident #32 did not reveal an assessment for self-administration of medication.Review of the care plan revised on 07/2/25, documented that Resident #32 had an activities of daily living self-care deficit related…

    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 · D2025-09-05 · 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, record review, menu review, and interview, the facility failed to ensure food was provided as per preference for 1 of 1 sampled resident, Resident #41, who voiced concerns with food choices.The findings included:Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact.Review of the current physician orders documented Resident #41 was ordered a regular diet.During an interview on 09/03/25 at 12:06 PM, Resident #41 stated she had asked for poached eggs and they wouldn't make them. Resident #41 stated she saw them on the menu.On 09/04/25 at 8:55 AM, Resident #41 was in the common area on 2S awaiting breakfast. Staff C, Certified Nursing Assistant (CNA) was observed taking the breakfast order from Resident #41 while showing the resident the menu.…

    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 before2025-09-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to provide a therapeutic diet for 2 of 2 sampled residents as evidenced by failure to ensure that Resident #38 and Resident 50 are provided with thickened liquids. The findings included:1) Record review revealed Resident #38 was admitted to the facility on [DATE]. The initial comprehensive assessment dated [DATE] documented a Brief Interview Mental Status score of 07 on a 0-15 scale, indicating the resident had moderate cognitive impairment. There was documented medical diagnosis of dysphagia (difficulty swallowing). Review of the physician order dated 06/18/25 revealed that Resident #38, was on a regular diet, pureed texture, honey thickened consistency. An observation was conducted on 09/02/2025 at 12:22 PM, Resident #38 was sitting in the wheelchair sleeping with bedside table in front of him. There was a packet of thicken it powder, a white styrofoam cup with light yellow liquid and a spoon inside of it and 2 other styrofoam cups 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to ensure accessibility of call lights for 3 of 4 sampled residents reviewed for accommodation of needs (Resident #56, #101, and #71). The finding included: The facility's policy titled, Call System, Resident dated September, 2022 revealed Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The resident call system remains functional at all times. 1) Resident # 56 was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, and Abdominal Aortic Aneurysm. The Brief Interview for Mental Status (BIMS) score for the resident on the quarterly Minimum Data Set with an assessment reference date of 03/24/24 was 9. This indicated the resident had mild cognitive impairment. On 05/06/24 at 11:43 AM, an interview was conducted with Resident #56 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · 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 record review and interviews, the facility failed to ensure medications were being administered timely for 1 of 1 sampled resident (Resident #71). The findings included: Review of the facility's policy titled, Medication Administration - General Guidelines dated May 2022 included in part: B. Administration 2) Medications are administered in accordance with written orders of the prescriber. 12) Medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Record review for Resident #71 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The resident had diagnoses that included: Encephalopathy, Parkinson's Disease, and Need for Assistance with Personal Care. Review of the Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to safely store medications for 1 of 1 sampled resident (Resident #54). The findings included: Review of the facility's policy titled, Bedside Medication Storage dated May 2022 included in part: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. Procedures C. For residents who self-administer medications the following conditions are met for bedside storage to occur: 1) The manner of storage prevents access by other resident. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident. Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with diagnosis 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure timely personal care and assist with feeding for 3 of 3 sampled residents (Resident #26 #79, and #59), reviewed for Activities of Daily Living(ADL's). Specifically, eating and incontinent care. The findings included: 1) During an interview on 02/13/23 with the daughter of Resident #26, she expressed concern about the resident not receiving assistance to eat her meals. During the interview, the daughter indicated she can communicate with her mom through her mom's gestors and hand movements. Review of the record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #26 has diagnosis to include Parkinson's Disease and Rheumatoid Arthritis. The resident was admitted to hospice services on 11/24/22. On 02/14/23 at 8:55 AM the resident was observed in her wheelchair beside her bed with her breakfast tray. The resident was attempting to eat however she was not able to get the food onto her spoon.…

    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 · D2023-02-16 · 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 observation, record review, and interview, the facility failed to ensure padded bed side rails were provided & properly used for 2 of 4 sampled residents reviewed for accidents, both of whom had a history of seizures (Residents #10 and #15). The findings included: 1) Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current care plan initiated on 11/04/20 revealed Resident #10 was at risk for seizure related injuries related to conversion disorder with seizures or convulsions. An intervention dated 02/09/22 revealed the use of bilateral upper half padded side rails for safety. An order dated 10/16/17 documented the use of two padded side rails for safety. The current Minimum Data Set (MDS) assessment dated [DATE] confirmed the diagnosis of seizures. During an observation on 02/13/23 at 10:26 AM, Staff A, Certified Nursing Assistant (CNA), had just finished providing personal care for Resident #10, and left the room, leaving the resident in the bed. A half…

    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 before2023-02-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement a new order for increased water flushes via enteral (tube feeding) means, for 1 of 2 sampled residents, who was ordered the increase related to an electrolyte imbalance (Resident #1). The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Further review of the record revealed the resident received all food and fluids via a tube. A physician progress note dated 02/13/23 revealed an elevated sodium level with a plan that increased the water flushes with the PEG feeding (percutaneous endoscopic gastrostomy/surgical placement of a feeding tube). The tube feeding water flushes had recently been increased to 150 ml (milliliters) every 4 hours. A Registered Dietician's (RD) progress note dated 02/14/23 documented to increase the tube feeding water flushes to 200 ml every 4 hours due to elevated BUN (Blood urea nitrogen), a lab value related to a person's hydration status, identified…

    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 · D2023-02-16 · tag F0725 — failed to have enough nursing staff — isolated
    Provide 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 4) Resident #5 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required extensive to total two-person assist with activities of daily living. An interview was conducted with Resident #5 with family at bedside. The resident stated they do not have enough people to help get people out of bed in a timely manner. The resident's family member referred to yesterday 02/15/22 when the resident was supposed to be out of bed in order to go to physical therapy at 10:00 AM. Resident #5 and family member stated they did not get him out of bed until after lunch, after 1:00 PM. The resident and his family member stated they just don't have enough staff to take care of our needs. Things like that happen on a regular basis. Based on interview, observation, record review, policy review, the facility failed to ensure sufficient staffing for 2 (4 North and 4 South) of 5 resident units, affecting the provision of care and services for 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent or greater; the medication error rate was 8%. Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #257. The findings included: A medication administration observation was conducted on 02/15/23 at 9:00 AM, with Staff Z, a Registered Nurse, for Resident #257. Staff Z was observed pouring 5 milliliters (ml) of iron in a medicine cup. The labeling on the iron medication was 5 ml/220 mg. Staff Z, after gathering up the rest of the resident's medications, stated the resident was out of her Prednisone. Staff Z stated she would check the emergency kit for the medication. Staff Z returned with 2 pills of Prednisone 5 mg each (total 10 mg). Staff Z proceeded to administer a total count of 8 pills, and 3 liquids, verified together with the surveyor. A medication reconciliation was conducted with the medications Staff Z administered to Resident #257, and the resident's orders on 02/15/23 at 10:15 AM. A review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure safe medication storage on 1 of 5 resident units (3S), as evidenced by two observations of an unlocked and unattended medication cart on two separate occasions (on 02/13/23), and observation of an unlocked and unattended treatment cart for at least 45 minutes on 02/13/23. The findings included: Review of the policy Medication Storage in the Facility dated April 2018 documented, B. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 02/13/23 at 9:57 AM, the treatment cart on the 3S unit was noted unlocked and unattended. The 3S unit was a locked unit for memory impaired residents, with a centrally located common area and nurse's station. The unlocked treatment cart was pushed up against a wall in the common area with the drawers facing outward (Photographic Evidence Obtained). At the time of this observation, eleven residents were noted in the common area. Two nurses…

    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 before2023-02-16 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to follow ordered therapeutic diet for 1 of 4 sampled residents reviewed for a special diet (Resident #257). The findings included: On 02/15/23 at 9:30 AM, Resident #257 was observed coughing, and her private duty aid (PDA) was heard yelling at the resident to spit it out. Upon entering the resident's room, the resident was observed spiting out pieces of bacon into a napkin. A review of Resident #257's meal ticket on her breakfast tray revealed a diet of mechanical soft food order. Staff Z, a Registered Nurse, came into the resident's room, looked at the strips of bacon on the resident's tray and said the resident was not supposed to have that. An interview with Speech Pathology (ST) was conducted at Resident #257's bedside on 02/15/23 at 10:06 AM. SP stated the resident should not be eating bacon on a mechanical soft diet.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-16 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure antibiotic stewardship for antibiotic use for 1 of 1 sampled residents reviewed for antibiotic stewardship (Resident #76); and failed to provide antibiotics for infected wound in a timely manner for 1 of 1 sampled residents (Resident #28). The findings included: A review of the facility's policy titled, Antibiotic Stewardship Policy, dated 03/02/21, documented the purpose for our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered, lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 1) An observation was conducted of Resident #76 on 02/14/22 at 11:00 AM. The resident was observed sitting up in bed with a private duty aid (PDA) at his bedside. Resident #76 had a loud coarse wet sounding cough. The PDA stated the resident had…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, interview, and policy review, the facility failed to ensure provision of the influenza (flu) and/or pneumococcal (pneumonia) immunizations for 3 of 5 sampled residents (Resident #21, #78, and #97). Resident #97 was admitted to the facility after November 30th and before March 31st, and the facility failed to ensure the influenza vaccine was administered within 5 days of admission. The facility failed to assess all three residents for the pneumococcal vaccine within 5 working days of admission and provide it within 30 days of admission, as per their own policy. The findings included: Review of the policy Influenza Vaccine revised October 2019 documented, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 2. Employees hired or residents admitted between October 1st and March 31st shall be offered the vaccine within five (5)…

    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 · D2023-02-16 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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, interview, and policy review, the facility failed to ensure the provision of COVID-19 vaccinations for 3 of 5 sampled Residents (Resident #21, #78, and #97). The findings included: Review of the policy Infection Control: COVID-19 Vaccination - Resident effective 10/19/20 documented, Screening - All residents prior to admission to the home, shall be screened for their COVID-19 vaccination status. Offer of Vaccination - Any resident without evidence of full vaccination status will be educated on the risks and benefits of being vaccinated for COVID-19 and offered the vaccine to be administered upon it's next availability. Evidence of this education and consent or declination will be signed, dated, and scanned to the resident's medical record. 1) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Further review of the record revealed the resident's last COVID-19 vaccination was 02/07/21, as documented by Florida Shots (a website that tracks all vaccines). 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-16 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide notification of discharge to the Ombudsman for 4 of 4 sampled residents reviewed, (Resident #102, 104, 72, 1) with the potential to effect all residents discharged from the facility. The findings included: 1). Resident #102 was admitted to the facility on [DATE] and discharged to another facility on 11/22/22. A discharge summary documented a planned discharge with physician's orders to another SNF (Skilled Nursing Facility). Resident #102 signed the discharge summary, acknowledging understanding and left the unit at 11.45 AM via wheelchair, accompanied by transport staff. The facility was not able to provide documentation or evidence that the Long-Term Care Ombudsman was notified of the discharge. 2). Resident #104 was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. A Health Status Note, dated 01/23/23 at 8:49 AM, documented, Note Text: Resident sent to [name of hospital] via emergency as ordered. Private aid at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-16 · tag F0885 — failed to notify residents/families about COVID-19 — widespread
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to proactively notify residents, their representatives, and families of any positive COVID-19 cases, by 5 PM the next calendar day following the occurrence, for the past two outbreaks reported by the facility (12/29/22 and 02/10/23). The findings included: During an interview on 02/13/23 at 1:40 PM, the Staff Developer/Interim Infection Control Preventionist (ICP) explained the facility's last resident COVID-19 outbreak began on 12/28/22, resulting in eleven positive residents, all residing on one unit. The ICP explained that no staff were positive at that time. This was confirmed by the Resident COVID-19 infection log that documented positive residents on 12/29/22, 12/30/22, and 01/04/23. Review of the Employee COVID-19 Tracking Log revealed one positive staff member, Staff M, Registered Nurse (RN), as of 02/10/23. The Interim ICP stated the Nursing Home Administrator (NHA) would be responsible for the notification to the residents, their representatives, and families. During an interview on 02/15/23 at 10:41 AM, when asked…

    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
  • No harm found · C2023-02-16 · tag F0886 — failed to test for COVID-19 as required — widespread
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure for each instance of resident COVID-19 testing, that all testing results were maintained in the resident record. The findings included: During an interview on 02/13/23 at 1:40 PM, the Staff Developer/Interim Infection Control Preventionist (ICP) explained they were able to do contact tracing testing for the past two outbreaks, one in December 2022 that encompassed the 3S unit, and one in February 2023 that encompassed the 3N unit. When asked where in the resident record the COVID-19 results were maintained, the Interim ICP explained, if a resident was positive, a progress note would be in the Electronic Medical Record (EMR) and the actual test results are all stored together, but not in the resident's medical record. During this continued interview, the regulation was reviewed with the ICP, and she voiced understanding and agreed they had not been ensuring all testing was maintained in the resident's record.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARMELITE SISTERS FOR THE AGED & INFIRM — 9 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 4 of 52.8+1.2 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 5 of 53.8+1.2 vs chain
Quality measures 3 of 53.9-0.9 vs chain
The other 8 homes this chain runs (chain average 2.8★, 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 / managerTypeRoleSince
CLARKE, JOHNIndividualCORPORATE DIRECTORsince 04/01/2024
CODY, MARYIndividualCORPORATE DIRECTORsince 04/01/2021
DALY, BETHIndividualCORPORATE DIRECTORsince 04/01/2021
FLYNN, KATHLEENIndividualCORPORATE DIRECTORsince 04/01/2021
HEERY, MARYIndividualCORPORATE DIRECTORsince 04/01/2021
LYNCH, PATRICIAIndividualCORPORATE DIRECTORsince 03/11/2023
MCDONOUGH, MAUREENIndividualCORPORATE DIRECTORsince 04/01/2021
MCMAHON, JOHNIndividualCORPORATE DIRECTORsince 04/01/2021
PEREIRA, MARYIndividualCORPORATE DIRECTORsince 04/01/2021
RANDALL, DIANEIndividualCORPORATE DIRECTORsince 04/01/2021
ROGERS, MARYIndividualCORPORATE DIRECTORsince 04/01/2021
SCHNEIDER, THOMASIndividualCORPORATE DIRECTORsince 04/01/2024
DIMARIA, LILLIANIndividualCORPORATE OFFICERsince 04/01/2021
GATHERS, PATRICIAIndividualCORPORATE OFFICERsince 07/01/2021
THE CARMELITE SYSTEM INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025
MACK, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
FORTIER, DANIELIndividualADP OF THE SNFsince 06/17/2020

CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$15.6M
Net patient revenuemost recent cost report
-25.9%
Operating marginrevenue minus expenses
$1.1M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 14%Other / private 34%

This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$477per resident / day
operating cost
$14,515per month
≈ monthly operating cost
$379per 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 105420. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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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