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Wilton Manors Healthcare & Rehabilitation Center

2675 N Andrews Ave, Wilton Manors, FL 33311 · For profit - Corporation · 147 certified beds · (954) 563-5711 Medicare & Medicaid certified

Call the home — (954) 563-5711 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$17,345 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (16% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,345 in federal fines (most recent 2025-06-19)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
300 E Oakland Park Blvd Ste 395 · (954) 874-5238 · Call to confirm hours
Pharmacy
Walgreens0.5 mi
3100 N Andrews Ave · (954) 568-0164 · Call to confirm hours
Grocery
3062 N Andrews Ave · (954) 561-8606 · Call to confirm hours
Park
NE 21st Ct · 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 5 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.8%8.7%15.4%better
Long-stay residents who lose too much weight2.5%5.5%5.4%better
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 symptoms5.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%2.5%3.3%better
Long-stay residents whose ability to walk worsened1.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.0%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.4%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control0.0%10.5%21.2%check this — see note marked star below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.8%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission23.0%26.1%22.6%typical
Short-stay residents with an outpatient ER visit8.3%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.702.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.461.151.80better

* 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.

39.6% 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 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.6%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
59.1%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.30
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 59.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 186 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 0.55 therapist hours per resident per day in 2025Q4 — more than 86% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 39% 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 14% — 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 SNF39.6%CMS range 30.5–50.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.2–12.410.7%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 discharge59.1%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 discharge60.2%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 discharge51.6%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 identified86.0%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 setting99.1%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 discharge92.2%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 stay0.6%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 worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 5.3–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 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

0.63
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.64
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.46
RN hoursweekends
16.5%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 147 beds and averages 135.0 residents a day — about 92% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 is at or above 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 3.78 hrs/resident/day on weekends vs 4.30 on weekdays — 12% thinner on weekends. RN hours go from 0.72 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 16% is below the national median of 45%.

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

Inspection trend

14 ↑
deficiencies at the latest standard inspection (2025-06-19)
5
at the previous standard inspection (2024-03-21)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2025-06-19 · 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 review of policy and procedure, record review and interview, the facility failed to ensure that residents received appropriate care and treatment to prevent an evolving change in condition and status for 1 of 1 sampled resident reviewed, Resident #113. The findings included: Review of the facility policy, titled, Change in a Resident's Condition or Status, provided the Director of Nursing (DON), revised May 2017, documented in the Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and the representative (sponsor) of changes in the resident's medical / mental condition and/or status (e.g. changes in level of care, billing / payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's condition . 2. A significant change of condition is a major decline or improvement in the resident's status that:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-19 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the American Dietetic Association titled National Dysphagia Level 2: Mechanically Altered Nutrition Therapy showed the following: for vegetables, it is recommended to be soft, well cooked, should be less than 1/2 inch, and easily mashed with a fork. 3a. Record review revealed Resident #230 was admitted to the facility on [DATE] with diagnoses of Unspecific Protein-Calorie Malnutrition, Unspecific Dementia, and Muscle Weakness. On 06/16/25 at 12:44 PM, an observation was conducted, during which Resident #230 was noted in her room eating her lunch meal, being assisted by staff. The meal ticket listed the following: a mechanically altered ground diet with pureed fruits and vegetables, collard greens, macaroni and cheese, a dinner roll, ground ham, and banana pudding. Closer observation of the food on the tray revealed that the pureed collard greens lacked a smooth consistency and were lumpy. 3b. Record review revealed Resident #106 was readmitted to the facility on [DATE] with diagnoses of Unspecific…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-19 · 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 observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen. The findings included: Review of the US Food and Drug Administration's (FDA) report, dated March 2022, showed the following: raw hamburger, ground for 1-2 days, and fresh poultry, stored for 1-2 days, in the refrigerator. Website: https://www.fda.gov/food/people-risk-foodborne-illness/refrigerator-freezer-chart-food-safety-moms-be. On 06/16/25 at 8:55 AM, during tour and observation in the kitchen, the following were noted: a. The Hydron strip was used to check 1 of 3 red sanitation buckets for the appropriate sanitation solution. It showed 0, indicating that no sanitation solution was noted in the bucket. b. The reach-in freezer was marked by visible water droplets and ice buildup on the top and bottom of the freezer. c. The walk-in refrigerator was noted to contain a box of raw chicken thighs 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-19 · 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 observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner while providing dining assistance during 1 of 3 dining observations conducted, affecting Resident #285. The findings included: Review of the facility's policy titled, Quality of Life - Dignity, dated August 2009, included the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. Record review for Resident #285 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia,…

    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 before2025-06-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure call light devices were within reach of 4 of 93 rooms, room numbers 23, 25, 29 and 104. The findings included: 1. On 06/16/25 at 9:53 AM, an observation was made of room [ROOM NUMBER] and both residents were in bed. Upon further observation of the bed near the window, it was observed the call light cord was wrapped around the bed rail with the call light push button dangling towards the back of the bed and not within reach. Photographic Evidence Obtained. At this time the resident was asked if he knew how to call the nurse if he needs assistance and he stated yes. Then it was observed that the resident was looking for the call light push button, stating he could not find it and was unable to reach the cord that was wrapped around the bed rail and not within reach. 2. On 06/16/25 at 10:14 AM, an observation of room [ROOM NUMBER] was conducted and both residents were sleeping in bed. During this observation, it was observed that 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to initiate a care plan for Enhanced Barrier Precautions (EBP) for 1 of 29 sampled residents, Resident #328. The findings included: 1. Record review documented Resident #328 was admitted on [DATE] with diagnosis of encounter for other orthopedic aftercare and displaced trimalleolar fracture of left lower leg, encounter for closed fracture with routine healing. The Medicare - 5 Day Minimum Data Set (MDS) dated [DATE]documented the Brief Interview of Mental Status (BIMS) score is 15, indicating no cognitive impairment. Review of the Physician's Orders showed Resident #328 had an order dated 05/20/25 for Enhanced Barrier Precautions: Surgical wound. Review of the care plan dated 05/31/25 documented Resident #328 had skin impairment localized in the left ankle and left foot. Goals were the healing of wounds without complications by the next review date. The interventions did not include Enhanced Barrier Precautions. In an interview conducted…

    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 before2025-06-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide assistance during dining for 1 of 1 sampled resident, reviewed for activities of daily living (ADLs), Resident #330. The findings included: 1. Record review documented Resident #330 was admitted on [DATE] and discharged on 06/16/25 with diagnoses that included Sepsis and Urinary Tract Infection (UTI). The Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 13, indicating mild cognitive impaired. Section GG of the MDS showed that Resident #330 needs Substantial / Maximal Assistance during dining. Review of Resident #330 care plan dated 05/14/25 documented Resident #330 was at risk for an alteration in nutrition and/or hydration. The interventions put in place included providing hands on assist with eating at meals and as needed and provide cues / encouragement during meals. During an observation conducted on 06/16/25 at 12:15 PM, Resident #330 was seen in…

    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 before2025-06-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility facility failed to ensure that services and treatment were provided to increase or maintain range of motion (ROM) and to prevent potential decrease in ROM, as ordered by physicians, for 2 of 2 sampled residents, reviewed for ROM, Residents #51 and #62. The findings included: Review of the facility's policy titled, Splints and Braces, undated, included the following: Procedures: 3. After therapy discharges the patient, the splints will be monitored by Assistant Director of Nursing (ADON) or designee, Director of Rehab Services (DOR) and/or designee. A new T.O will be obtained to indicate the wearing schedule and the responsible department with updated care plan. 5. If a patient is issued a splint / brace and cannot be located, go to the ADON or DOR and get the correct or replacement of splint/brace. 8. Report to nurse any adverse observations. Review of the facility's policy titled, Contracture Management, undated, included the following: 3.…

    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 · D2025-06-19 · 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 review of policy and procedure, observation, interview and record review, the facility failed to follow proper technique and infection control practices during catheter care observation for 1 of 1 sampled resident observed, Resident #113. The findings included: Review of the facility policy, titled, Urinary Catheter Care, provided by the Director of Nursing (DON), revised September 2014, documented in the Policy Statement: Purpose: the purpose of this procedure is to prevent catheter-associated urinary tract infections (UTI). Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: .Maintain Unobstructed Urine Flow: .3. The urinary drainage bag must be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder Record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-19 · 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 observations, interviews, and record review, the facility failed to complete a nutrition assessment in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #231. The findings included: Review of the facility's policy titled Nutrition Assessment, revised in October 2017, showed the following: as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for residents at risk for or with impaired nutrition. Review of the facility's policy titled Weight Assessment and Interventions, revised September 2008, showed the following: The nursing staff will measure resident weights on admission, times 2, then monthly thereafter, the next day, and weekly for two weeks thereafter. If no weight…

    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 · D2025-06-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have dialysis communication sheets readily available for the continuation of care for 1 of 2 sampled residents reviewed for dialysis, Resident #231. The findings included: Review of the facility's dialysis contract dated 05/27/21 revealed the following: Access to Records-provider will ensure that the Facility has any and all records of supplies and services provided to, and any flow sheets, progress notes, physician orders, incident reports, and other documentation which reflect the quality of treatments received by the Covered Patients. Providers and Caregivers will communicate information necessary to the Facility and/or Physician for continuing care of each Covered Patient, including medication administration for maximum therapeutic effect. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes and Anemia. The 5-day Minimum Data Set (MDS) assessment…

    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
Show the remaining 19 citations
  • Potential for harm · D2025-06-19 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to accurately assess a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and establish triggers for PTSD for 1 of 1 sampled resident reviewed for PTSD, Resident #58. The findings included: Record review revealed Resident #58 was admitted to the facility with diagnoses of Chronic Post Traumatic Stress Disorder, Anxiety, and Major Depressive Disorder. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. Review of the physician's order showed the following: Sertraline (psychotropic medication) 150 milligrams at bedtime for Major Depressive Disorder dated 03/14/24. Aripiprazole (antipsychotic medication) tablet 2 milligrams one time a day for Schizoaffective Disorder, dated 09/23/23. An interview was conducted on 06/17/25 at 4:36 PM with Resident #58, who stated he had served in the [name] War and that he has PTSD. He…

    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 · D2025-06-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes, and Anemia. The 5-day MDS dated [DATE], showed that Resident #231 had a BIMS score of 9, indicating moderate cognitive impairment. The Initial Nutrition assessment, dated 06/10/25, showed that Resident #231 was at increased risk for altered nutritional status, and it was recommended to provide double protein with meals. In an observation conducted on 06/16/25 at 12:37 PM, Resident #231 was eating his lunch meal. The closer observation showed the meal ticket with the following: Controlled Carbohydrates Renal diet, double protein, baked pork chops, buttered green, buttered pasta, and cornbread. The lunch plate was observed with the following: 3 ounces of grilled chicken, 4 ounces of buttered green, 4 ounces of buttered pasta, and one piece of cornbread. This showed that Resident #231 did not get the double portion of the protein for lunch. Based on observations, interviews 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 · D2025-06-19 · 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 4. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder and Unspecific opened wound. An order was noted for Enhanced Barrier Precautions-wound every shift, which was dated 05/20/25. An observation was conducted on 06/16/25 at 11:30 PM of Staff B, Occupation Therapist, who was noted coming out of Resident #38's room with a gown. She was observed walking over to a Personal Protective Equipment (PPE) box located on the wall in the hallway. She grabbed a surgical mask with her bare hands and continued to put on gloves without practicing hand hygiene first. Staff B took a Hoyer lift and walked into Resident #38's room to assist him from the bed to the wheelchair with another staff member who was already in the room. Based on observations, interviews, and record review, the facility failed to implement Center for Disease Control and Prevention (CDC) guidelines and recommendations for Enhanced Barrier Precautions (EBP) for 4 of 45 sampled…

    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 · Dcited before2024-03-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat a resident with a left-hand contracture for 1 of 1 sampled resident reviewed for a range of motion (ROM), Resident #108. The findings included: Review of the facility's policy, titled, Splints and Braces, revised on January 2, 2024, revealed the following: Donn patient splint / brace according to positioning / splinting instructions. Allow the patient to wear a splint / brace per the therapist's recommended wearing schedule and tolerated. Review of the facility's policy, titled, Contracture Management, revised on January 2, 2024, revealed that treatment plans will be geared towards minimizing or possibly alleviating residents noted contractures. Record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, repeated Falls, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/19/24, revealed a Brief Interview of Mental Status (BIMS) score…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-21 · 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 observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent further weight loss for 1 of 5 sampled residents reviewed for nutrition, Resident #101. The findings included: Review of the facility policy, titled, Nutrition Assessment, revised in October 2017, revealed the following: Any weight change of 5% or more since the last weight assessment will be verified, and nursing will contact the Dietitian for further evaluation. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria where the percentage of body weight loss == (usual weight actual weight) (usual weight) - 100]: a. month 5% weight loss is significant; greater than 5% is…

    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 before2024-03-21 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the correct food consistency for 3 of 3 sampled residents who were on a mechanical soft / chopped, who were observed during dining, Resident #34, Resident #87, and Resident #230. This has the potential to affect 30 residents on a mechanical soft/chopped diet. The census at the time of the survey was 138 residents. The findings included: Review of the facility's diet manual dated 2019, provided by the facility's Dietitian, showed the following foods that were allowed on the mechanical soft diet: canned fruits, cooked or steamed fruit desserts, ripe banana, diced watermelon, diced ripe melon, diced ripe strawberries, and smooth fruit sauces. It further showed that all other fresh fruits were not allowed. Review of the International Dysphagia Diet Standardization Initiative dated 2019, provided by Staff C, Speech Therapist, revealed the following: Level 5 minces and moist diet, to provide fruits served minced or chopped or mashed…

    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 before2024-03-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain a proper sanitizing solution in the central kitchen for 2 of 3 red buckets observed during the initial tour of the kitchen; and failed to offer or encourage hand hygiene prior to dining for 5 of 5 sampled residents observed during dining, Residents #10, #24, #381, #99, and #69. The findings included: 1. The first visit to the central kitchen was conducted on 03/18/24 at 8:50 AM, accompanied by the Culinary Food Manager. The following issues were observed: a. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the first red bucket. Further observation showed the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 1st red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. b. The Culinary Food Manager used a testing strip…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-21 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide restorative rehabilitation services in a manner that promotes the highest practicable level of functioning for 1 of 5 sampled residents receiving restorative services during dining (Resident #10). The findings included: Review of the facility policy, titled, Restorative Nursing Services,, revised in July 2017, revealed that Residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may start on restorative nursing programs upon admission, during stay or when discharged from rehabilitative care. Restorative goals may include: Supporting and assisting the Resident in adjusting or adapting to changing abilities. Maintaining dignity, independence, and self-esteem. Developing and strengthening physiological and psychological resources. Resident #10 was admitted to the facility on [DATE] with diagnoses of Dysphagia, dementia, and anxiety disorder. The Quarterly Minimum Data…

    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 · Ecited before2022-12-08 · tag F0550 — failed to protect resident dignity and rights — pattern
    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

    Based on observation and interview, it was determined the facility failed to treat 3 of 3 sampled residents, Resident's #95, #105,and #281, and potentially 132 facility residents, with respect and dignity in a manner that promotes enhancement of quality of life that includes providing drinking cups and glasses with meals. The findings included: During the observation of the lunch meal of 12/05/22, breakfast meal of 12/06/22, and lunch meal of 12/06/22, it was observed that all residents who received beverages in disposable cartons, including milk, thickened milk, juice and supplements, did not receive a drinking cup for the cartons' beverages. Specifically, the facility residents were required to drink straight from the disposable cartons. The facility residents were noted to receive 1 - 3 beverages on the meal trays. Interviews conducted with sampled Residents' #95, #105, and #281 at this time voiced their displeasure to be required to drink from disposable cartons. Both residents' #105 and #281 stated they have stopped drinking whole milk and thickened milk due to having…

    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 · E2022-12-08 · 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, record review and review of policy and procedure, it was determined that the facility failed to ensure it secured and locked over-the-counter (OTC) expired and prescription medications for 5 of 5 residents observed during an observational room tour, Resident #80, Resident #77, Resident #68, Resident #230 and Resident #40; failed to ensure it kept its facility emergency crash cart locked and secured; failed to ensure it disposed of an expired stock medication in the South wing Treatment cart; and failed to ensure it secured loose unidentified medication pills for 1 of 6 observed medication carts during the Medication Storage Observation for the North wing medication cart. The findings included: Review of facility policy and procedure on 12/07/22 at 2:30 PM, titled, Storage of Medications, provided by the Director of Nursing (DON), revised date 08/2020, documented in part: Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations and records review, the facility failed to ensure that 1 of 2 sampled residents (Resident #102) received an adaptive call light to notify staff of her needs. The findings included: Review of the electronic clinical record revealed that Resident #102 was diagnosed with Cerebral Infarction due to Unspecified Occlusion or Stenosis Of Right Middle Cerebral Artery; Hemiplegia, Unspecified Affecting Left Nondominant Side; and Other Reduced Mobility. On 12/05/22 at 1:21 PM, during an interview with Resident #102, she said that her neck, right elbow, and shoulder were hurting her. She was asked to use her call light to request for assistance. She said that her call light was too far away. Observation conducted during the conversation showed the call light was on the floor on the right side of the resident's bed. Photographic Evidence Obtained. The call light was then placed in the Resident's right hand, and she was asked to press on it. She tried but was unable to press on the balloon 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 records review, the facility failed to ensure protection of 1 of 1 sampled resident's, Resident # 328, personal property from loss or theft. The findings included: Review of the electronic Census record showed that Resident # 328 was admitted to the facility on [DATE] and discharged from the facility on [DATE]. Review of the Social Service notes, dated [DATE] revealed that the resident's daughter and wife had reported missing a kindle and electric shaver which belonged to the resident. The notes showed that Staff searched the storage room, but the items were not located. A gift card was issued on [DATE] to the family. The Social Worker (SW) noted that the missing items were not on the inventory sheet. On [DATE] at 11:36 AM, Resident #328's family member reported that they made multiple calls to the facility to retrieve Resident #328's personal properties left at the facility subsequent to Resident #328's discharge from the facility. According to Resident #328's relatives, the list of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · 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 review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with activities of daily living: nail grooming for 1 of 1 sampled resident's observed, Resident #60. The findings included: Review of the facility policy and procedure on 12/07/22 at 2:30 PM, titled, Care of Fingernails/Toenails, provided by the Director of Nursing (DON), revised February 2018, documented, in part: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident .General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and records review, the facility failed to comprehensively assess 1 of 1 sampled resident (Resident #39) to determine her needs for hearing aids; and failed to promptly identify Resident #39's need for reading glasses and ensure an ophthalmological evaluation was performed timely. The findings included: Review of the electronic clinical record showed Resident #39 was diagnosed with Unspecified Hearing Loss, Unspecified Ear Primary Diagnosis Present on admission of 02/10/22. The resident had diagnoses to include Major Depressive Disorder, Recurrent, In Remission, Unspecified effective 09/15/22. Review of the Physicians' order showed no evidence for hearing aids services. Review of the Minimum Data Set (MDS) dated [DATE] and updated 04/01/22, 09/01/22 and 11/22/22 presented conflicting data in relation to Resident #39's current noticeable visual and hearing deficits. The last updated MDS, dated [DATE], Section B (Hearing) documented that Resident #39 had no hearing aid, in Section…

    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 · D2022-12-08 · 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 record review, observations, interviews and the facility's policy review, the facility failed to ensure that residents received care and services for the provision of parenteral fluids consistent with professional standards of practice for 1 of 1 sampled resident reviewed for Intravenous Antibiotic (IV) therapy, Resident #178, as evidenced by failure to change the IV Access Line dressing per the facility's policy and the facility's Intravenous (IV) Access Line Maintenance Protocol; failed to administer / infuse IV antibiotic in the pharmacy prescribed timeframe; and failed to have physician orders for IV flushes to maintain the IV-line which were being administered by the nurses. The findings included: 1. Review of the facility's policy, titled, Midline Dressing Changes, revised on April 2016, documented in part, .change midline catheter dressing 24 hours after catheter insertion, every 5- 7 days . Review of the facility's policy titled Intravenous Administration of Fluids and Electrolytes provided by…

    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 · D2022-12-08 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policy and procedure, interview, and record review, it was determined that the facility failed to ensure that it maintained eighteen (18) months' worth of daily nurse staffing data, as recorded. The findings included: Review of the facility policy and procedure on 12/07/22 at 2:30 PM, titled, Posting Direct Care Daily Staffing Numbers, provided by the Director of Nursing (DON), revised July 2016, documented in part, Policy Statement: Our facility will post, on a daily basis, for each shift, the number of nursing personnel for providing direct care to resident . 8. Records of staffing information for each shift will be kept for a minimum of eighteen (18) months or as required by state law (whichever is greater) . During an interview conducted on 12/05/22 at 12:10 PM with the Staffing Coordinator, she was asked whether or not the facility had maintained the full required 18-month daily nurse staffing data. She stated she had not maintained the full schedule, in either paper or computerized form, dating back from between June 2021 through December 2021. The Staffing…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to provide lab services to meet the needs on 1 of 1 sampled resident, Resident #99, reviewed for labs. The findings included: During an environment tour conducted on 12/07/22 at 1:00 PM accompanied with the Corporate Maintenance Director, the specimen refrigerator located in the Soiled Utility Room located in South [NAME] Unit was observed. Further investigation of the refrigerator noted what appeared to be a Urine specimen. A review of the Lab [company name] Sheet that was with specimen collection tube noted it was documented as urine (UA) for Resident #99. Further review of the lab sheet did not document a date that the urine specimen was collected. A review of the specimen tube noted the urine was documented as collected on 12/05/22. The surveyor requested of the Corporate Nurse to investigate why the specimen had not been collected by the lab on 12/05/22. Following the request, the Corporate Nurse submitted…

    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
  • Potential for harm · D2022-12-08 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined the approved Pureed Diet menu did not meet nutritional needs and was not followed for 14 facility residents with physician ordered Pureed Diets, which included 3 of 3 sampled Residents #28, #88, and #167. The findings included 1. During review of the approved menu for the lunch meal of 12/05/22 and breakfast meal of 12/06/22, the following was noted to be documented: Lunch Meal (12/05/22): 4 ounces Pureed Dinner Roll (pureed diet) 4 ounces Chocolate Pudding (pureed diet) 1 Tsp [teaspoon] Chopped Parsley (garnish) No documentation of an alternate purred vegetable. Breakfast Meal (12/06/22) Slivered [NAME] Onions (garnish). 2. During the observation of the lunch meal in the Main Kitchen on 12/05/22 at 11:30, the following was noted: (a) Observation of the tray line in the main kitchen on 11/05/22 at 11:30 AM noted the Pureed Buttered Dinner Roll had not been prepared and would not be served. Once the surveyor informed the Certified Dietary Manager (CDM) there was a menu omission, an attempt was made to use white…

    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 · D2022-12-08 · 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, it was determined the facility failed to follow physician ordered therapeutic diet for Fluid Restriction for 1 of 5 sampled residents, Resident #281, reviewed for nutrition. The findings included: Review of facility's Policy & Procedures, in part, for Restricting Fluids, noted the following: General Guidelines: < Follow specific instruction (physician order) including fluid intake or restrictions. < Record fluid intake on the intake side of the intake and output record, Record fluid intake in ML's. < When placed on restricted fluid, remove the water pitcher and cup from the room. < Be sure an intake and output record is maintained in the resident's room. During the observation of the lunch meal conducted on 12/05/22 at 1:00 PM, it was noted the meal tray was delivered to the room of Resident #281. Further observation noted the meal tray ticket documented 'Mechanical Soft, Renal. Fluid Restriction 1500 cc (D:720)'. The tray ticket did not have documentation 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

“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

$17,345 in federal fines across 1 penalty.

  • $17,345 — penalty dated 2025-06-19

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 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.7+0.3 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 5Cypress Care CenterWildwood, 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 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
WILTON MANORS SNF HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/23/2022
FL MASTER OPCO HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 07/27/2022
MORTON, SHALONDAIndividualW-2 MANAGING EMPLOYEE—since 07/27/2022
SHELBY, JACKIndividualCORPORATE OFFICER—since 07/27/2022

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.6M
Net patient revenuemost recent cost report
+8.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 46%Medicare 22%Other / private 32%

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

$358per resident / day
operating cost
$10,874per month
≈ monthly operating cost
$392per 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 2026-09-01 — CMS provider number 105119. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, 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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