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Cypress Care Center

490 S Old Wire Rd, Wildwood, FL 34785 · For profit - Limited Liability company · 180 certified beds · (352) 748-3322 Medicare & Medicaid certified

Call the home — (352) 748-3322 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
$25,799 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $25,799 in federal fines (most recent 2025-03-04)
  • its independent health-inspection rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
CannaMD0.5 mi
4076 E SR-44 · (855) 420-9170 · Call to confirm hours
Pharmacy
342 Shopping Center Dr · (352) 748-9900 · Call to confirm hours
Grocery
405 S Main St · (352) 748-3474 · Call to confirm hours
Park
100 W Wonders St · Typically dawn to dusk
Place of worship
7279 Warm Springs Ave · (352) 748-3255

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 held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.2%8.7%15.4%better
Long-stay residents who lose too much weight6.5%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.1%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 symptoms24.6%4.6%6.5%worse
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 injury3.7%2.5%3.3%typical
Long-stay residents whose ability to walk worsened3.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.1%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 control4.3%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication3.3%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.1%94.7%79.4%better
Short-stay residents rehospitalized after admission26.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.072.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.721.151.80typical

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

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

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

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

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

35.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

35.0%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
56.5%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 56.5% 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 131 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF35.0%CMS range 24.6–43.951.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.7–15.110.7%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 discharge56.5%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 discharge43.5%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 discharge42.8%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 identified94.6%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 setting93.6%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 discharge65.7%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 stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.2%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 hospitalization8.8%CMS range 5.8–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.511.02Oct 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

0.29
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.69
Total nurse hours/ resident / day
0.15
RN hoursweekends
53.1%
Total nursing turnover
52.9%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 172.5 residents a day — about 96% occupied, or roughly 8 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 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.35 hrs/resident/day on weekends vs 3.83 on weekdays — 12% thinner on weekends. RN hours go from 0.35 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as 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

10
deficiencies at the latest standard inspection (2025-03-20)
9
at the previous standard inspection (2023-12-07)

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Ecited before2025-03-20 · tag F0761 — failed to label and store drugs safely — pattern
    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 record the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 5 out of 8 medication carts and 1 out of 4 units reviewed for unattended medication. Findings include: During an observation on [DATE] at 9:17 AM Resident #267 was lying on her bed with intravenous medication running. There was a medication cup on top of Resident # 267 which contained white circular tablets and a red color tablet. During an interview on [DATE] at 9:17 AM Resident #267 stated, The nurses leave my medication at bedside because I prefer to take them when I get out of bed. During an interview on [DATE] at 9:27 AM Staff A, Certified Nursing Assistant (CNA), stated, [Resident #267's name] has a medication cup that contains medications at her bedside. During an interview on [DATE] at 9:28 AM Staff B, License Practical Nurse (LPN), stated, I thought she (Resident #267) had taken her medications.…

    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 · E2025-03-20 · 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, interview, and policy review, the facility failed to ensure food is safely stored, covered, and cooked in a manner that preserves the nutritional value, and that sanitation was maintained in the kitchen. Findings include: A walk-through tour of the kitchen was conducted on 3/17/25 at 09:12 AM with the facility Administrator. An observation was made of a large bulk bin of flour with a partial open lid and food particles were observed in the bin with the flour. There were 3 bins that were dirty on the exterior with buildup of dirt and splashes. There was a large can opener with the base affixed to a stainless-steel prep table that had a buildup of brown, red, and black particles and food particles on the blade portion of the can opener. There was a deep fryer that was full of dirty oil, that was brownish in color and the oil had food particles and a buildup of food particles on the deep fryer top, edges, and sides. There were 3 dirty rags on the stainless food table and were not stored in sanitizing or cleaning buckets. There were approximately 34 food serving…

    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 before2025-03-20 · 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 observations, interviews, and record reviews, the facility failed to ensure each resident was provided with an assessment which accurately reflects the resident's status for 3 (Resident #111, #24, #4) of 10 residents reviewed for communication, nutrition and activities of daily living. Findings include: 1.) During an interview conducted in Spanish on 3/17/2025 at 10:42 AM with Resident #111, she stated, Communication with staff can be hard. I speak Spanish and it is very hard to communicate with staff. They have a few staff members that speak Spanish, but they may not be always available. I am Hispanic of Cuban decent. Review of Resident #111's Minimum Data Set (MDS) Comprehensive Quarterly assessment dated [DATE] documented Resident #111 was not Hispanic, and her preferred language was English. Review of Resident #111's Social Service admission Evaluation dated 11/22/2024 read, Ethnicity: E2d. Yes, Cuban. Summary /Additional Comments: .Patient speak Spanish. During an interview on 3/19/2025 at 10:05…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 2 (Resident #111 and #91) of 5 residents reviewed for communication and respiratory care. Findings include: 1.) During an interview in Spanish on 3/17/2025 at 10:42 AM, with Resident #111, she stated, Communication can be hard. I speak Spanish and it is very hard to communicate with staff. They have a few staff members that speak Spanish, but they may not be always available. During an interview on 3/19/2025 at 10:01 AM, Staff G, License Practical Nurse (LPN,) stated, [Resident #111 Name] can speak a little bit of English. If she does not understand what I am saying to her [Resident #111] I will get a Spanish speaking employee to translate. During an interview on 3/19/2025 at 10:05 AM, Staff H, LPN, stated, [Resident #111 name] sometimes will not understand our conversation, she speaks Spanish. I will get the Environmental Service Supervisor or a restorative aide that speak Spanish in order to better communicate with her. During an interview on 3/19/2025 at 10:15 AM, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure professional standards of practice were implemented for 2 (Resident #124 and #147) of 4 residents reviewed for gastric tubes. Findings include: 1.) During an observation on 3/19/2025 at 9:17 AM Staff G, License Practical Nurse, (LPN) entered Resident #147's room wearing a gown, gloves, and surgical mask. Staff G, without checking placement or residual, began to flush the gastric tube with 30 milliliters of water. Staff G began to administer medications via gastric tube performing flushes of 5milliters of water in between each medication administration. Staff G finished administering medications and flushed the gastric tube with 30 milliliters of water. Review of Resident #147's physician order dated 3/16/2025 read, Flush feeding tube with 30ML (milliliters) of water before and after medication administration every shift. Review of Resident #147's physician order dated 3/16/2025 read, Check tube placement and for residual before addition of feeding, flush, or medications. If residual is 100cc…

    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 before2025-03-20 · 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 observations, interviews and record reviews the facility failed to provide care and services in accordance with professional standards of practice for 2 (Resident #267, #118)) of 10 residents reviewed for central venous access devices and medication administration. Findings include: 1.) During an observation on 3/17/2025 at 9:17 AM, Resident #267 was lying in bed. A single lumen midline was observed on the upper right arm with a transparent dressing dated 3/7/2025 in black marker. Review of Resident #267's Medical Certification for Medicaid Long Term Care Service and Patient Transfer form dated 3/7/2025 documented a midline dated 3/7/2025. Review of Resident #267's physician orders did not document any intravenous catheter dressing changes orders. Review of Resident #267's physician orders did not document orders for flushing intravenous central line. Review of Resident #267's physician orders dated 3/10/2025 read, Fetroja Intravenous Solution Reconstituted 1 GM [Gram] (Cefiderocol Sulfate Tosylate) Use 1500 mg [milligrams] intravenously every 8 hours for Wound…

    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 · D2025-03-20 · 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 observations, interviews, and record reviews, the facility failed to ensure the residents environment was free from accident hazards when 2 (Resident #77 and Resident #139) of 4 residents were not assessed for safe smoking. Findings include: During an observation on 3/17/2025 at 9:20 AM, Resident #77 was observed with a pack of cigarettes and a lighter on the bedside table. During an observation on 3/17/2025 at 10:45 AM, Resident #77 was observed on the smoking patio smoking a cigarette. During an interview on 3/18/2025 at 1:15 PM, Resident #77 stated I keep my cigarettes and my lighter [with me]. In fact, I need to go and get cigarettes. During an interview on 3/20/2025 at 10:15 AM, Staff K, Certified Nursing Assistant (CNA), stated He [Resident #77] keeps his cigarettes and lighter with him. Review of the admission nursing assessment for Resident #77 documented in Section R, Smoking Safety, questions 7-12 were blank. These questions described resident observations for demonstrating safe smoking…

    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 · D2025-03-20 · 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

    Based on observation, interviews and record reviews, the facility failed to ensure that residents fed by enteral means received the care and services as prescribed by the physician for 1 Resident (Resident #134) of 3 residents reviewed for tube feeding services. Findings include: During an observation on 3/19/2025 from 12:39 PM until 3:00 PM of Resident #134, there was no bolus feed given as per physician's orders at 2:00 PM. During an interview on 3/19/2025 at 3:00 PM with Staff I, LPN, stated I did not have an enteral feeding to administer to (Resident #134 Name). Review of the physician's order dated 1/25/2025 for Resident #134 read, Enteral Feed. Every shift for GTF [gastric tube feed] Jevity 1.5 vis feeding tube at 100 cc/hr for 12 hours, off at 5 am and on at 5 pm. Bolus 325 ml (milliliters) via enteral feeding tube at 6 am and 2 pm. During an interview on 3/19/2025 at 3:00 PM following the review of the physician's orders for Resident #134, Staff I, LPN, stated I didn't see that portion of the order. During an interview on 3/19/2025 at 3:05 PM, Staff N, LPN stated, (Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · 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

    Based on observations, interviews, and record reviews, the facility failed to ensure services for respiratory care, consistent with professional standards of practice ,were provided for 2 (Resident #124 and # 91) of 6 residents reviewed for oxygen therapy. Findings include: During an observation on 03/17/25 at 11:25 AM, Resident #124 was resting calmly with eyes closed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an observation on 3/18/2025 at 8:27 AM, Resident #124 was resting calmly with eyes closed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an observation on 3/19/2025 at 2:15 PM with Staff G, License Practical Nurse (LPN), Resident #124 was lying in bed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an interview on 3/19/2025 at 2:15 PM, Staff G, LPN, stated, [Resident #124's name] has orders for 2 liters per minute. The flow rate is incorrect and needs to be adjusted. Review of Resident #124's physician order dated 2/25/2025 read, May apply O2 @ 2 LPM (oxygen at 2 liters…

    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 · D2025-03-20 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain a urinalysis when ordered by the physician for 1 (Resident #82) resident of 5 residents reviewed for unnecessary medications. Findings include: Review of Resident #82's admission record documented medical diagnosis including obstructive and reflux uropathy (a condition where urine flow is blocked or flows backward into the bladder). Review of Resident #82's physician order dated 3/12/2025 reads, UA(urinalysis) with C/S (culture and sensitivity). Review of Resident #82's medication administration record(MAR), treatment administration record (TAR), nursing progress notes and laboratory results revealed no documentation of a UA with C/S being completed or resident refusing laboratory test. During an interview on 3/17/2025 at 10:03 AM Resident # 82 stated, I am having pain in my abdomen, and it feels like I am getting a UTI (urinary tract infection). I told the staff several days ago and they said they would collect it(a urine specimen) but they haven't done it. During an interview on 3/18/2025 at 10:38 AM Staff N,…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-03-04 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure guidance was provided to 2 of 3 residents, Residents #1 and #2, of informed health status treatment and changes related to the enrollment/disenrollment from health plan coverage, and failed to develop a written policy and procedure regarding the process of assisting beneficiaries with changing their health care coverage. Findings include: 1) Review of the medical record for Resident #2 contained disenrollment paperwork signed by Resident #2 for the disenrollment from the resident's current health insurance coverage to different health insurance coverage. The record did not provide documentation of an attestation signed by the facility staff that assisted with the change in enrollment for Resident #2 attesting that Resident #2 or the representative requested the change or that the beneficiary or representative received and understood the minimum required information. The documentation was requested from the Community Liaison/Admissions Director. The Community Liaison/Admissions Directed stated, The facility staff did…

    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 · Ecited before2023-12-07 · tag F0761 — failed to label and store drugs safely — pattern
    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, record review, and interview, the facility failed to ensure that opened blood glucose test strips were labeled in 3 of 6 medication carts observed. Findings include: During an observation of Medication Cart #1 in Hall 200- Spanish Village Unit on [DATE] at 9:10 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:10 AM, Staff D, Licensed Practical Nurse (LPN), stated, I do not write the date on the bottle when I open them. I do not know what the policy for this facility is. During an observation of Medication Cart #2 on Hall 200- Spanish Village Unit on [DATE] at 9:30 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:30 AM, Staff C, LPN, stated that the glucose strips were supposed to be dated when the bottle was opened and were good for 90 days after they were opened. During an interview on [DATE] at 10:54 AM, Staff F, LPN, stated…

    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 · E2023-12-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 3. During an observation on 12/4/2023 at 9:22 AM, Resident #62 was lying in bed with a dressing on the right upper arm dated 11/29/2023. During an observation on 12/4/2023 at 12:10 PM, Resident #62 had a dressing on the right upper arm dated 11/29/2023. Review of Resident #62's physician order dated 10/30/2023 showed the order to cleanse the right arm with normal saline, pat dry, apply Xeroform and cover with pad two times a day for skin tear. Review of Resident #62's Treatment Administration Record for November 2023 and December 2023 revealed the wound care and dressing change was completed on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023. During an interview on 12/6/2023 at 1:53 PM, the Director of Nursing stated that the dressing had not been changed since November 29, 2023, and that the nurses documented that the skin care on the upper right arm was completed. The Director of Nursing stated that the nurses documented the dressing changes in error when the dressing was not completed. She confirmed the dressing…

    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 before2023-12-07 · 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 record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurate for 1 of 3 discharged residents, Resident #167. Findings include: Review of Resident #167's medical records showed the resident was admitted to the facility on [DATE] and discharged to an Assisted Living Facility (ALF) on 11/13/2023. Review of Resident #167's physician order dated 11/7/2023 reads, Pt.'s [Patient's] spouse requested discharge to [ALF's name] on Monday, 11/13/23. [Staff Name] w [with]/ [ALF's name] to arrange Home Health (if needed) and transportation, PU [pick up] approx. [approximately] 11Am. DME: 18' WC [wheelchair] w/leg rest. DC [discharge] with all medications and belongings. Review of Resident #167's Discharge, Return Not Anticipated MDS dated [DATE] showed the resident was discharged on 11/13/2023 to a short-term general hospital. The MDS was signed on 11/15/2023 at 2:54 PM. Review of Resident #167's modified MDS dated [DATE] showed the resident was discharged on 11/13/2023 to home under…

    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 before2023-12-07 · 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

    Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received nail care for 1 of 3 reviewed residents, Resident #132. Findings include: During an observation on 12/3/2023 at 9:40 AM, Resident #132 was sitting outside of his room in his wheelchair. Resident #132's fingernails on his right and left hands were long with dark brown and black substances underneath the nails. There was an injury on the resident's right cheek. Review of Resident #132's care plan, revised on 10/24/2023, revealed the resident had a self-care deficit related to generalized weakness and psychomotor deficit. Resident #132's care plan documented activities of daily living self-care interventions that included assist with nail shaping, keep nails short and clean. Review of Resident #132's personal hygiene task documentation dated 11/23/2023 through 12/3/2023, revealed no documentation indicating the resident had refused to participate in personal hygiene care. During an interview on 12/3/2023 at 9:44 AM, Staff 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 · Dcited before2023-12-07 · 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 observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents receiving intravenous infusion via Peripherally Inserted Central Catheter (PICC) Line, Residents #18 and #62. Findings include: 1. During an observation on 12/5/2023 at 9:15 AM, Resident #18's PICC line dressing was not dated and there was no gauze or bio-patch under the dressing. There was dry residue under the dressing and there was no needleless connector at the end of the valve (Photographic evidence obtained). During an interview on 12/5/2023 at 9:15 AM, Resident #18 stated, I had this line in the hospital before I came. No one has changed it [dressing] here. Review of Resident #18's admission records showed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin-Resistant Staphylococcus Aureus (MRSA) bacterial infection of the right lower leg. Review of Resident #18's Catheter…

    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 · D2023-12-07 · 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

    Based on observation, interview, and record review, the facility failed to ensure residents maintained the nutritional status for 1 of 6 residents reviewed for nutrition, Resident #81. Findings include: Review of Resident #81's physician order dated 10/27/2023 reads, NAS (No Added Salt) diet Finger Food texture, Thin consistency, Finger foods preferred. Review of Resident #81's care plan revised on 9/22/2023 revealed the resident was at risk for alteration in nutrition and/or hydration. Resident #81's care plan documented nutritional interventions that included Provide diet as ordered. Offer and provide alternate as needed and honor food preferences. Review of Resident #81's weight history showed a weight of 155 pounds on 10/25/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 1.03% weight loss. Further review showed a weight of 169.6 pounds on 7/5/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 9.55% weight loss. During an observation on 12/4/2023 at 1:09 PM, Resident #81 received ham, scalloped potatoes, beets in juice and fruit in juice as her midday meal.…

    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 · D2023-12-07 · 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 medication error rate was below 5%. The facility's medication error rate was 7.14%. Findings include: 1. During an observation on 12/5/2023 at 8:50 AM, Staff G, Licensed Practice Nurse (LPN), administered Brimonidine Tartrate 0.1% Ophthalmic Solution for Resident #65's eyes. Record review of Resident #65's medication order showed the order for Brimonidine Tartrate 0.2% Ophthalmic Solution to instill one drop both eyes two times a day for glaucoma. Review of the medication package label reads Brimonidine 0.1% Ophthalmic solution, instill one drop in both eyes two times a day for glaucoma. During an interview on 12/6/2023 at 9:41 AM, Staff G, LPN, stated, I didn't check the medicine against the order. I should have. During an interview on 12/6/2023 at 12:34 PM, the Director of Nursing (DON) stated, The nurse would call the family, doctor, supervisor, and fill out an incident form for a wrong medication dose or wrong medication given. 2. During an observation on 12/5/2023 at 9:03 AM, Staff G, LPN,…

    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 · D2023-12-07 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure adaptive eating equipment or devices were provided to 1 of 6 residents reviewed for nutrition, Resident #469. Findings include: During an observation on 12/4/2023 at 9:17 AM, Resident #469 was using plastic disposable utensils to eat his breakfast. During an observation on 12/5/2023 at 12:40 PM, Resident #469 was using plastic disposable utensils to eat his meal. Review of Resident #469's physician order dated 9/15/2023 showed the order reads, Pt [Patient] to utilize built-up utensils for all meals. During an interview on 12/4/2023 at 12:43 PM, the Speech Therapist stated that she was aware Resident #469 was supposed to be using built-up utensils. During an interview on 12/6/2023 at 8:00 AM, the Certified Dietary Manager (CDM) stated, The dishwasher is not functioning currently and residents are being given disposable dishware. The specialized utensils should have been going out to residents but the new staff is in need of further training.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff performed assessment and proper dressing changes for Peripherally Inserted Central Catheter (PICC) Line and attach a needleless connector to the PICC line valve to help prevent the development and transmission of infection for 1 of 3 residents, Resident #18, and failed to ensure infection control standards were followed for 1 of 3 residents reviewed for indwelling urinary catheter, Resident #470. Findings include: 1. During an observation on 12/5/2023 at 9:15 AM, Resident #18's peripherally inserted central catheter (PICC) line dressing was not dated and there was no gauze or bio-patch under the dressing. There was dry residue under the dressing and there was no needleless connector at the end of the valve (Photographic evidence obtained). During an interview on 12/5/2023 at 9:15 AM, Resident #18 stated, I had this line in the hospital before I came. No one has changed it [dressing] here. Review of Resident #18's admission…

    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 · Fcited before2022-06-23 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 6 of 8 medication carts. Findings include: During an observation of medication cart #1 conducted on 6/20/2022 at 8:57 AM with Staff A, Licensed Practical Nurse(LPN), there was one opened Levemir insulin with no date opened, no resident identifier, and not in the original pharmacy packaging, one opened Lantus insulin pen with no date opened or expiration date, one opened Latanoprost Ophthalmic Solution with no date opened or expiration date, and one medication cup with eleven medications with no resident identifier or list of what the medication were. During an interview conducted on 6/20/2022 at 9:05 AM Staff A, LPN, stated, All insulin should be labeled with the resident who they are for and when they are opened or expire. I know who the medications are for, but I shouldn't have left them in the cart. During an observation of medication cart #2 conducted on 6/20/2022…

    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 · Fcited before2022-06-23 · tag F0880 — failed to prevent and control infections — widespread
    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, and record review the facility failed to ensure infection control procedures were followed to prevent the possible spread of infection. Findings include: 1. During an observation on 6/21/2022 at 9:33 AM of the laundry room it showed the door between the soiled laundry hold and the clean laundry area was propped open with a bucket. In the clean utility room near the dryers there was a pink bottle of water/ice on the table that contained folded linen and curtains. A Styrofoam cup containing ice and water was on the metal frame four tier laundry cart that contained clean linen. During an interview on 6/21/22 at 9:42 AM the Director of Environmental Services stated, In the staff's defense the air conditioner was broken, and the staff had the liquids to stay hydrated. The staff has been in-survived on not having drinks in the laundry or having drinks in the linen areas. The doors should not be propped open. I don't know why the door is propped open. 2. During an observation 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · 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 — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to ensure residents were provided with information of the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 1 of 5 residents, Resident #167, reviewed for advance directives. Findings include: Review of Resident #167's admission Packet Attempt Log dated 3/8/2022 read, Patient want (sic) family member to review agreement prior to signing. Sibling would be coming. Resident #167's record failed to show follow up documentation related to providing Resident #167 information concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. During an interview on 6/21/2022 at 10:54 AM, the Social Services Director confirmed Resident #167's record does not contain documentation the facility had followed up with Resident #167 to provide information concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission, for 1 of 3 newly admitted residents, Resident #518, in a total sample of 52 residents. Findings include: Review of Resident #518's medical record admission documentation read the resident was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood caused by organs not working as well as they should), dementia in other diseases classified elsewhere with behavioral disturbance, muscle weakness (generalized), history of falling, essential (primary) hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), pure hyperglyceridemia (high concentration of triglycerides in the blood), need for assistance 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide services in accordance with professional standards of practice for gastrostomy tube medication administration for 2 of 6 residents, Residents #58 and #157 sampled for gastrostomy tubes, in a total sample of 52 residents. Findings include: Review of the medical record for Resident #58 documented the resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, generalized anxiety disorder, hypertensive retinopathy, Parkinson's disease, status post gastrostomy tube (a tube in the stomach that brings food directly to the stomach), iron deficiency, presence of left artificial hip joint, left ankle contracture, right ankle contracture, hypothyroidism, essential (primary) hypertension, cerebral infarction, (stroke) dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. Review of the physician orders dated 12/18/2019 reads, Check tube feeding…

    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 before2022-06-23 · 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, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 3 residents, Residents #130 and #46, in a total sample of 52 residents. Findings include: During an observation on 6/20/2022 at 3:13 PM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. During an observation on 6/21/2022 at 8:08 AM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. During an observation on 6/22/2022 at 8:58 AM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. Review of Resident #130's admission records showed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, dysphagia, oral phase, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, cognitive communication deficit,…

    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 before2022-06-23 · 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 and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for 4 of 13 residents who received respiratory care services, Resident #50, #58, #166 and #105. Findings include: 1. An observation of Resident #50 was conducted on 6/20/2022 at 10:00 AM. Resident #50 was observed resting in bed with her eyes open. Oxygen was being administered at 2.5 liters per minute via nasal cannula. An observation of Resident #50 was conducted on 6/21/2022 at 9:52 AM. Resident #50 was observed lying in her bed. An oxygen concentrator was at the side of the bed. The oxygen concentrator was administering oxygen at 2.5 liters per minute via nasal cannula. An observation of Resident #50 was conducted on 6/22/2022 at 8:49 AM. Resident #50 was lying in her bed. An oxygen concentrator was beside her bed and was administering oxygen at 2.5 liters per minute via nasal cannula. The oxygen tubing was lying beside the resident on the bed. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to ensure garbage and refuse was properly disposed of. Findings include: During an observation on 06/20/22 at 09:19 AM with the Certified Dietary Manager in the back of the facility building outside in the dumpster area there is debris consisting of soiled briefs in plastic bags, soiled gloves, plastic cups, paper, straws and milk cartons near garbage receptacles, not in the garbage receptacles. (Photographic evidence obtained) During an interview on 06/20/22 at 09:20 AM the Certified Dietary Manager confirmed the observation, and stated, That trash is not supposed to be there. A request was made for the policy and procedure for garbage disposal. The Certified Dietary Manager stated, No policy exist, we are to put the garbage in the dumpsters and the area should be clean.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-09-24 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include:During an observation on 9/22/2025 at 9:15 AM, the facility posted nurse staffing information for September 15, 2025, September 16, 2025, September 17, 2025 and September 18, 2025. There was no nurse staffing information for 9/22/2025 (Photographic evidence obtained).During an observation on 9/23/2025 at 9:00 AM, the facility posted nurse staffing information for September 15, 2025, September 16, 2025, September 17, 2025 and September 18, 2025. There was no nurse staffing information for 9/23/2025.During an interview on 9/23/2025 at approximately 10:00 AM, the Administrator stated, The expectation is for the staffing to be posted daily by Staffing Coordinator. That should have been taken care of and updated yesterday.

    Nursing and Physician Services 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

$25,799 in federal fines across 1 penalty.

  • $25,799 — penalty dated 2025-03-04

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 3 of 54.7-1.7 vs chain
The other 35 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Alhambra Healthcare & Rehabilitation CenterSaint Petersburg, FL 1 of 5Lady Lake Specialty Care Center and RehabLady Lake, FL 2 of 5Lehigh Acres Healthcare & Rehab CenterLehigh Acres, FL 2 of 5North Beach Healthcare And Rehabilitation CenterNorth Miami Beach, FL 2 of 5Park Meadows Healthcare & Rehabilitation CenterGainesville, FL 2 of 5Rockledge Healthcare & Rehabilitation CenterRockledge, FL 2 of 5Sunset Lake Healthcare And Rehabilitation CenterVenice, FL 2 of 5Village Place Healthcare And Rehabilitation CenterPort Charlotte, FL 2 of 5Villages Healthcare And Rehabilitation Center, TheLady Lake, FL 3 of 5Apollo Healthcare & Rehabilitation CenterSaint Petersburg, FL 3 of 5Club Healthcare And Rehabilitation Center At The VThe Villages, FL 3 of 5Greenbriar Healthcare Rehabilitation And Nursing CBradenton, FL 3 of 5Grove Healthcare And Rehabilitation Center And RehHernando, FL 3 of 5Lexington Healthcare And Rehabilitation CenterSaint Petersburg, FL 3 of 5Shore Acres Care Center And RehabSaint Petersburg, FL 3 of 5South Campus Care Center And RehabLeesburg, FL 3 of 5The Club At Lake GibsonLakeland, FL 3 of 5Viera Healthcare And Rehabilitation CenterViera, FL 4 of 5Advanced Care CenterClearwater, FL 4 of 5Lakes Of Clermont Health And Rehabilitation CenterClermont, FL 4 of 5North Healthcare And Rehabilitation CenterSaint Petersburg, FL 4 of 5North Lake Care Center And RehabLake Park, FL 4 of 5Ridgecrest Healthcare And Rehabilitation CenterDeland, FL 4 of 5The Lodge Healthcare And Rehabilitation CenterOcala, FL 4 of 5Wilton Manors Healthcare & Rehabilitation CenterWilton Manors, FL 5 of 5Carlton Shores Healthcare And Rehabilitation CenteDaytona Beach, FL 5 of 5Gardens Healthcare & Rehabilitation CenterDaytona Beach, FL 5 of 5Isle Healthcare & Rehabilitation CenterOrange Park, FL 5 of 5Kendall Lakes Healthcare And Rehab CenterMiami, FL 5 of 5Plaza Health And RehabGainesville, FL 5 of 5Ponce Therapy Care Center And Rehab, TheSaint Augustine, FL 5 of 5Terrace Healthcare & Rehabilitation CenterGainesville, FL 5 of 5Unity Healthcare And Rehabilitation CenterMiami, FL 5 of 5Villa Healthcare & Rehabilitation CenterDeland, FL 5 of 5Woodland Grove Healthcare & Rehabilitation CenterJacksonville, FL

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
ARBOR NURSING HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/23/2022
FL MASTER OPCO HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/27/2022
FL SNF TRUST IOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/27/2022
FL SNF TRUST IIOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/27/2022
GRAHAM, DWAYNEIndividualW-2 MANAGING EMPLOYEEsince 07/27/2022
ELLENBOGEN, MOSSIndividualCORPORATE OFFICERsince 07/27/2022

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.

$20.6M
Net patient revenuemost recent cost report
-0.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 68%Medicare 16%Other / private 16%

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

$330per resident / day
operating cost
$10,025per month
≈ monthly operating cost
$330per 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 105649. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-20, 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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