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Westgate Health And Rehabilitation Center

2300 Village Blvd, West Palm Beach, FL 33409 · For profit - Limited Liability company · 120 certified beds · (561) 478-1800 Medicare & Medicaid certified

Call the home — (561) 478-1800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 2025
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
Worth asking about
  • 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
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
2425 Presidential Way · (561) 683-9203 · Call to confirm hours
Pharmacy
1760 Palm Beach Lakes Blvd · (561) 847-7481 · Call to confirm hours
Grocery
1741 Palm Beach Lakes Blvd · (561) 619-6264 · Call to confirm hours
Park
N Congress Ave · (561) 582-7992 · 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 rating3★
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 increased4.3%8.7%15.4%better
Long-stay residents who lose too much weight11.5%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 infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.6%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 injury0.0%2.5%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened10.6%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.2%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control14.0%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table17.1%8.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine98.3%94.7%79.4%better
Short-stay residents rehospitalized after admission33.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit4.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.042.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.501.151.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

56.1% 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 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.1%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
45.0%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 45.0% 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 60 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF56.1%CMS range 45.8–66.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.4–12.710.7%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 discharge45.0%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 discharge53.3%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 discharge38.3%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 identified98.0%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 discharge96.0%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 stay0.0%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 worsened4.1%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 hospitalization7.5%CMS range 4.0–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.56
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.35
Total nurse hours/ resident / day
0.36
RN hoursweekends
58.8%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 114.6 residents a day — about 96% occupied, or roughly 5 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.16 hrs/resident/day on weekends vs 3.42 on weekdays — 8% thinner on weekends. RN hours go from 0.63 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-08-07)
7
at the previous standard inspection (2024-04-11)

Deficiencies are unchanged from the previous inspection. 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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2025-12-15 · 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 administrative and clinical record review and interviews, the facility failed to ensure that all allegations involving abuse, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, as evidenced by the staff failure to inform the appropriate administrative staff of a reported allegation of abuse in a timely manner affecting 1 of 3 sampled residents reviewed (Resident # 1), who apparently made multiple contacts with staff informing them of the alleged abuse before the facility made an attempt to act upon this allegation days later. The findings included:An interview was conducted on 12/15/25 beginning at approximately 2:30 PM with Resident #1 via a visual sign language interpretation line. Resident # 1 is a deaf mute who was admitted to the facility on [DATE] with diagnoses which included Discitis, Collapsed Vertebra, Radiculopathy, Type 2 Diabetes, Hypertension, Hyperlipidemia, Hypothyroidism, Insomnia, and Unspecified Hearing Loss. 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
  • Potential for harm · D2025-08-07 · 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 observation, record review and interview, the facility failed to treat 1 of 1 sampled resident with dignity as evidenced by not providing Resident #37 with a urinal.The findings included:Record review revealed Resident #37 was admitted to the facility on [DATE]. Review of quarterly assessment, dated 05/18/25, documented a Brief Mental Status (BIMS) score of 03 on a 0-15 scale, indicating severe cognitive impairment.During an observation on 08/04/25 at 10:29 AM, the resident was noted to have a medium size clear bowl under his bed with amber colored urine in it. When asked what was in the bowl underneath the bed, the resident stated, Pee. When the resident was asked why he was using a bowl to pee in, the resident stated, That's what I have to pee in. When asked why he was not using a urinal, the resident stated, I don't have one. Photographic Evidence Obtained.During an observation on 08/05/25 at 11:45 AM, Resident #37 was observed lying in his bed. An empty clear bowl, similar to the one observed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · 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 interview and record review, the facility failed to ensure appropriate care and services for 2 of 27 sampled residents, as evidenced by the failure to administer medications timely for Residents #27 and #117, both of whom voiced complaints.The findings included:1. Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. During a phone interview on 08/05/25 at 5:44 PM, a family member of Resident #27 voiced concerns that the nurses at the facility were not administering medication timely. The family member stated the medications were often administered late, and that at times the morning medications were late and then the evening medication were early. During an interview on 08/07/25 at 10:03 AM, when asked the expectation regarding the administration times…

    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 · D2025-08-07 · 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 observation, record review and interview, the facility failed to provide treatment to promote wound healing for 1 of 2 sampled residents as evidenced by not changing the dressing as ordered for Resident #11's pressure ulcer.The findings included:Record review revealed Resident #11 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15 scale, indicating no cognitive impairment. Review of a wound care note documented by the wound care doctor on 07/30/25, indicated Resident #11 had a non-healed, stage 3 pressure ulcer on her sacrum (bone below the spine above the tailbone) that measured 3cm length x 2.5cm width x 0.6 cm depth.Review of the current care plan dated 07/07/25 documented Resident #11 was at risk for skin breakdown due to weakness and incontinence, with a goal that the resident will have no further skin impairment with an intervention to perform preventative skin…

    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 before2025-08-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, record review and interviews, the facility failed to ensure that 2 of 5 sampled residents with indwelling Foley catheters (urinary drainage device) received proper care and assessment as evidenced by failure to assess Resident #117 for removal of the Foley catheter in a timely manner and ensure the Foley catheter was secured with a statlock (device to prevent dislodgement); and failure to assess Resident #123 for removal of the Foley catheter in a timely manner. The findings included:The finding included: Review of the facility policy review, titled, Standards and Guidelines: Catheter Care-quality of Care, revised 01/2004, documented in part: .Standard: The facility will maintain infection guidelines related to catheter use and catheter care to minimize catheter associated infections. Procedure: 5. Changing indwelling catheters or drainage bags routinely and at fixed intervals is not recommended. Rather it is suggested to change catheters and drainage bags based on clinical…

    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 · D2025-08-07 · 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, record review, observation and interviews, the facility failed to follow their weight assessment policy for 1of 4 sampled residents, as evidenced by not reweighing Resident #68 after a significant weight gain.The findings included:Review of the facility policy, titled, Weight Assessment revised on 08/2023, documented, in part, .Weight assessment: 2. Weight Variance changes that are undesired or unplanned since the last weight assessment will be retaken as soon as practical for confirmation. If the weight is verified, nursing will communicate with the Dietician and/or the physician. Record review revealed Resident #68 was admitted to the facility on [DATE]. Review of quarterly assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 on a 0-15 scale, indicating mild cognitive impairment. Review of the care plan dated 07/15/24 revealed Resident #68 was at risk for alteration in nutrition / hydration related to his diagnosis of Depression, MS (multiple…

    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 before2025-08-07 · 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 observation, interview, record review, policy review and professional standards, the facility failed to ensure respiratory services were adequately provided for 2 of 2 sampled residents as evidenced by the failure to provide oxygen as per physician order for Resident #91 and failure to assess Resident #105 during a nebulizer treatment.The findings included: 1.Review of the facility's Policy for Oxygen Administration, revised 12/2023, included instructions to review the physician's order for oxygen administration, and to adjust the oxygen delivery device so that the flow of oxygen administered met the resident's needs. Record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses that included Chronic Respiratory Failure, unspecified whether with Hypoxia or Hypercapnia, and Tracheostomy Status. The resident's documented Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE], was 8, indicating the resident had moderate cognitive…

    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 before2024-08-27 · 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 observation, clinical and administrative record review, and interview, the facility staff failed to ensure that 2 of 3 sampled residents, Resident # 1 and #2, received the necessary care and services as related to the resident's gastrostomy tube and site and skin assessments, as evidenced by the facility failure to provide evidence that care and services were provided for a resident with a gastrostomy tube, failed to properly assess and provide evidence of care and services for a gastrostomy tube site after removal, and failed to provide evidence that weekly skin assessments were completed for residents. The findings included: Review of the facility's policy and procedure for Administering Medications through an Enteral Tube, revised 01/2024, documented, in part, the following regarding Enteral Tube Care: 1. Cleanse enteral feeding site per the physician orders. Typically, one time per day with normal saline or soap and water. May leave enteral feeding site open to air or cover with a dry dressing as…

    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 · E2024-04-11 · 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 observation, interview, record review, and policy review, the facility failed to ensure proper disinfecting of glucometers (devices to obtain a blood sugar level) for 2 of 3 sampled residents observed (Residents #23 and #19); failed to properly disposing of a used lancet for 1 of 3 sampled residents (Resident #71); failed to ensure proper hand hygiene during the passing of meal trays for 1 of 2 floors (second floor); failed to implement enhanced barrier precautions (EBPs) for 2 of 11 sampled residents (Residents #18 and #359); and failed to ensure personal protective equipment (PPE), for use for with enhanced barrier precautions, was readily accessible for use with residents on 2 of 2 floors (first and second floor). At the time of the survey, there were 16 residents' rooms identified as needing PPE, to include gowns, for proper implementation of EBPs. The census at the time of survey was 110. The findings included: Review of the policy, titled, Blood Sampling - Capillary (Finger Sticks), revised…

    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 · D2024-04-11 · 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 timely smoking privileges as per resident choice and schedule for 2 of 5 sampled residents who smoke, Residents #159 and #259. At the time of the survey, there were five residents residing in the facility who smoked. The findings included: Upon entrance to the facility, an observation at the first-floor nurses' station revealed a sign that documented, Smoking Times: 10 AM, 2 PM, 4 PM, and 6:30 PM. Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Although the Brief Interview for Mental Status (BIMS) score had not yet been completed, review of the progress notes documented the resident was alert and oriented. During an interview on 04/09/24 at 9:03 AM, Resident #159 stated there were different Certified Nursing Assistants (CNAs) assigned to the smoking area at different times throughout the day, and they were never on time. During an observation at the first-floor nurses' station on 04/09/24 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
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-04-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurate Minimum Data Set (MDS) assessments for 3 of 34 sampled residents, related to the Brief Interview for Mental Status (BIMS) score for Resident #43, antibiotic use for Resident #3, and discharge location for Resident #108. The findings included: 1. Review of the record revealed Resident #43 was admitted to the facility on [DATE]. Review of the Annual MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6. The BIMS score is determined in part by asking the resident to repeat a pattern of words. During observations and attempted interviews on 04/08/24 at 11:06 AM and on 04/09/24 at 9:24 AM, Resident #43 did not verbally respond. During an interview in the morning of 04/08/24, Staff K, Certified Nursing Assistant (CNA), confirmed Resident #43 could not speak or move, but would only blink her eyes for yes and no questions. During an interview on 04/11/24 at 11:32 AM, when…

    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 · Dcited before2024-04-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide the appropriate treatment and services related to a clinically justified indwelling urinary catheter for 1 of 6 sampled residents, Resident #42. The findings included: Review of the record revealed Resident #42 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and had memory problems. This MDS also documented Resident #42 had an indwelling urinary catheter and was totally dependent upon staff for all care. Further review of the record revealed orders dated 03/01/24 for staff to provide indwelling catheter care every shift as needed, and to irrigate the catheter using 60 ml (milliliters) of normal saline every eight hours as needed for blockage, leakage, increased sediment, or decreased output. An additional order dated 03/02/24 had instructions to change and date the catheter securement…

    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 · D2024-04-11 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an intravenous peripherally inserted central catheter (PICC) line dressing was changed as ordered for 1 of 1 sampled resident, Resident #362. The findings included: Record review revealed that Resident #362 was admitted to the facility on [DATE], with diagnosis that included Septicemia (blood poisoning by bacteria). The admission Minimum Data Set (MDS) assessment, reference date 03/29/24 (which was completed and ready to export), recorded a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #362 was cognitively intact. This MDS recorded no mood or behavior issue. Subsequent review of the clinical record evidenced a physician order dated 03/24/24 of Ceftolozane-Tazobactam (an antibiotic) Intravenous Solution Reconstituted 1.5 (1-0.5) GM to use 1.5 gram intravenously every 8 hours for wound infection until 04/22/2024. An additional physician order dated 03/24/24 documented for the PICC line dressing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-11 · 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 observation, interview, record review, and policy review, the facility failed to ensure care and services for oxygen use for 2 of 3 sampled residents, Residents #59 and #55. The findings included: Review of the policy, titled, Oxygen Administration, revised 12/2023, documented, in part, General Guidelines: . 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physicians' orders and/or facility protocol. 4. Store oxygen tubing in a hygienic manner (i.e. labeling bag with date tubing was changed). 1. Review of the record revealed Resident #59 was admitted to the facility on [DATE], and moved to her current room on 04/15/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented oxygen was in use. Review of the vital sign record revealed oxygen saturations on 04/08/24 and on 04/09/24 were taken those mornings while the resident was on oxygen. Review of the record revealed an order dated 10/15/23 for the use of continuous oxygen at 2…

    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 · D2024-04-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to implement physician ordered blood pressure monitoring parameters for 1 of 6 sampled residents, Resident #78, as evidenced by lack of BP documentation and to ensure adequate monitoring. The findings included: Review of the record revealed Resident #78 was admitted to the facility on [DATE], with a diagnosis that included Essential Primary Hypertension (high blood pressure). Further review of the record revealed an order dated 09/26/23 to give Lisinopril 20 mg (milligrams) by mouth one time a day for Hypertension. The order also included a monitoring parameter to hold the medication for a systolic blood pressure (SBP) reading of less than 130. Review of the January 2024, February 2024, March 2024, and the current April 2024 Medication Administration Record (MAR) revealed Resident #78's blood pressure results were not documented. Review of the vital signs section of the electronic record revealed the following: a. Blood pressure (BP) results…

    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 · D2023-10-30 · 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 clinical and administrative record review and staff interview, the facility failed to ensure that clinical records were complete and accurately documented the implementation of prescribed medications and treatments for 1 of 3 sampled residents reviewed, Resident #1, as evidenced by staff failure to ensure all telephone orders were accurately recorded in the clinical record and the nurses' initial placed in the appropriate box to depict the medication and treatment orders were documented and implemented for Resident #1. The findings included: The facility's policy, titled, Administrating Medications, documented, in part, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 2 Units (100 & 200 Units) that included residents' rooms, storage areas, and common areas. The findings included: During the initial resident screenings conducted by the surveyors on 01/09/23 and the Environment Tour conducted on 01/11/23 at 10 AM accompanied with the Director of Maintenance, the following were noted: First Floor (100 Unit): a. First Floor Dining Room: Two of two ceiling vents were noted to be heavily soiled and black type mold matter. b. Physical Therapy room [ROOM NUMBER]: Room floor perimeter was heavily soiled and not being cleaned on a regular basis. Room windows noted to be covered with a white film. c. Physical Therapy room [ROOM NUMBER]: Two of two ceiling vents were noted to be heavily soiled and dust laden. Main Hallways: the hallways near the nurses' stations and south hallway were heavily soiled 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-12 · 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, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included failure to ensure proper temperature and chemical sanitizing levels in the dish machine and 3-compartment sink, failure to store food to prevent contamination / food borne illness, failure to ensure hot and cold foods are held at regulatory temperatures, and failure to ensure silverware is handled in a sanitary manner. The findings included: 1. During the initial food service / kitchen sanitation tour conducted on 01/09/23 at 9:00 AM, accompanied with the Food Service Director (FSD), the following was noted: (a) Observation noted the high temperature dish machine was in use by staff. At the request of the surveyor, the final rinse temperature was taken and noted to be 175 degrees F (Fahrenheit). The surveyor informed the Food Service Director (FSD) the regulatory minimum final rinse temperature was 180 degrees F. At the FSD's request, 3 more attempts were conducted to check the final rinse temperature 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 an accurate assessment, reflective of the resident's status at the time of the assessment for 2 of 29 sampled residents (Resident #10 and #109), as evidenced by Resident #10 did not a smoking assessment completed after a significant change and Resident #109 had an inaccurant assessment completed related to disharge. The findings included: A review of the facility's policy, titled, Smoking Guidelines, revealed, in part, Evaluate patients / residents that smoke utilizing the Smoking Evaluation tool either (a) upon admission/move-in; (b) when a previous non-smoking patient/resident takes up smoking; (c) if unsafe smoking practices are observed in a current smoker; or, (d) when a patient/resident that smokes has a significant change in medical condition. 1. Record review revealed Resident #10 was initially admitted to the facility on [DATE] for rehabilitation with a history of Chronic Kidney Disease, Osteomyelitis of the left foot, Hyperthyroidism,…

    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 · Dcited before2023-01-12 · 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 interview, the facility failed to coordinate care with Hospice for 1 of 1 sampled resident for hospice care (Resident #31). The findings included: Resident #31 was admitted to the facility on [DATE]. A comprehensive assessment, dated 12/09/22, documented the resident had mild cognitive impairment and required total two-person assistance with activities of daily living. The assessment further documented the resident received hospice services. Resident #31 was care planned for hospice services, with interventions that included hospice staff to visit to provide care, assistance, and/or evaluation. Record review revealed an order, dated 12/05/22, for Resident #31 to be admitted to hospice. Review of Resident #31's progress notes revealed a physician note, dated 12/02/22, that documented the resident's case was discussed with family members. The resident lost his apartment and had nowhere to live. Family wanted the resident to remain in facility with hospice services. A progress note, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess 1 of 1 sampled resident (Resident #322), who was admitted with Foley catheter (urinary catheter), for continued need for Foley catheter and possible removal of the Foley catheter . The findings included: Resident #322 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive two-person assist for activities of daily living. The assessment further documented the resident had a Foley catheter. Record review revealed an order, dated 01/05/23, to maintain indwelling catheter for obstructive uropathy (an obstruction in the urinary tract). Further record review did not reveal any documentation of a trial or attempt to remove Resident #322's Foley catheter. An interview was conducted with Resident #322's representative on 01/12/23 at 12:00 PM. The representative stated Resident #322 did not have a Foley catheter prior to the admission 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-12 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 treatment for 1 of 1 sampled resident reviewed for psychosocial behaviors (Resident #31), as evidenced by lack of non-pharmalogical interventions and lack of follow-up with a psychiatrist. The findings included: A review of the facility's policy, titled, Behavior Management Guidelines, dated 03/2022, documented in part: non-pharmacological interventions should be attempted prior to the use of any psychoactive medication. The policy further documented: Patients, families / responsible parties are educated regarding the risks / benefits of psychoactive medications prior to the first dose being administered, and signed consents are obtained. Resident #31 was admitted to the facility on [DATE]. A comprehensive assessment, dated 11/11/22, documented the resident had no cognitive impairment, and required extensive two-person assistance with activities of daily living. The assessment further documented the resident had moods of feeling down 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-12 · 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, interview and record review, the facility to follow physician ordered fluid restrictions for 1 of 7 sampled residents reviewed for nutrition (Resident #265) The findings included: Review of the facility's Guideline and Procedure for Fluid Restriction noted the following: Purpose: To facilitate the management and communication of the patient's individualized Fluid Restriction plan by the interdisciplinary team. Procedure: #3 - Dietitian recommends an update to the order to include the amount per shift for nursing. #5 - No water pitcher at bedside, unless part of the individualized beverage plan. #7 - The nurse acknowledges on the MAR/TAR [Medication Administrator Record / Treatment Administration Record] the fluids that were provided per order. During the observation of the breakfast meal conducted on 01/09/23, it was noted Resident #265 appeared to be underweight / malnourished and with cognitive impairment. The meal tray was to be served to the room of Resident #265. Further observation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-12 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 provide snacks at bedtime per physician order for 1 of 7 sampled residents reviewed for nutrition (Resident #41). The findings included: Resident #41 was initially admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, long term current use of insulin, and Atherosclerotic Heart Disease. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/08/22 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident is cognitively intact. On 01/09/23 at 11:47 AM, Resident #41 was interviewed as part of the initial pool process. The resident stated that his morning blood sugars have been low and he is supposed to get snacks at night but he is not always getting them. Resident #41 stated he would like to have a sandwich at night like a ham and cheese sandwich, but all that is available at night are graham or saltine crackers. A review was conducted of the resident's electronic medical…

    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 · D2023-01-12 · 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

    Based on observation, interview and record review, the facility failed to provide appropriate adaptive eating equipment for 1 of 7 sampled residents reviewed for nutrition (Resident #74). The findings included: Review of clinical record of Resident #74 noted the following: Date Of admission: readmission - 05/03/22 Diagnoses: Cognitive Communication Deficit, Dysphagia, Disorder of Muscles and Seizures Current Physician Orders: 09/23/22 - Angle spoon, angel form, scoop dish for all meals for dominate Right Hand 07/22/22 - CHO Controlled No Added Salt (NAS). MDS (Minimum Data Set): dated 12/08/22 included: Sec C: BIMS= 14 - (Cognition intact) Sec D: No Mood Issues Sec G: Eating = Supervision Sec K: 62 (inches) / 171# (pounds), Therapeutic Diet. Care Plan, dated12/29/22, included: *ADL Self Care deficit related to physician limitations < Angle spoon, and fork, and scoop dish for all meals for Right dominate hand. During the observation of the lunch meal in the main kitchen on 01/09/23 at 11:30 AM, it was noted the meal tray for Resident #74 included both a right-angled spoon and fork…

    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
  • No harm found · Bcited before2025-08-07 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 accurate Minimum Data Set (MDS) assessments for 2 of 27 sampled residents, as evidenced by inaccurate medication documentation for Resident #2 and inaccurate fall documentation for Resident #57.The findings included:1. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident was being administered medications to include a hypoglycemic medication, which was used for diabetes or high blood sugar levels.Review of the corresponding Medication Administration Record (MAR) for the seven-day look-back period of 07/09/25 through 07/15/25 lacked any documented administration of a hypoglycemic medication.During a side-by-side record review and interview on 08/07/25 at 11:54 AM, Staff C, MDS Coordinator, agreed with the inaccuracy. 2. Review of the record revealed Resident #57 was admitted to the facility on [DATE]. Review of the MDS…

    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

“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 ONYX HEALTH — 11 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 3 of 54.2-1.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 2 of 53.6-1.6 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 10 homes this chain runs (chain average 4.2★, 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 / managerTypeRoleShareSince
WESTGATE REHAB HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/04/2023
BP WESTGATE TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/05/2023
LF WESTGATE TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/05/2023
BALDO, ADELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/03/2023
BROWN, PAULETTEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/05/2023
NASAR, MOHAMMADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
SIEW, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/02/2025
WILDES, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
FRIEDMAN, LEOPOLDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/07/2025
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 05/05/2023

CMS files one row per role, so the 13 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$6.9M
Net patient revenuemost recent cost report
-15.6%
Operating marginrevenue minus expenses
$335K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 5%Other / private 38%

This home reported $335K 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

$356per resident / day
operating cost
$10,810per month
≈ monthly operating cost
$308per 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 105911. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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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