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Winter Garden Rehabilitation And Nursing Center

12751 W Colonial Drive, Winter Garden, FL 34787 · For profit - Limited Liability company · 120 certified beds · (407) 877-6636 Medicare & Medicaid certified

Call the home — (407) 877-6636 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Oct 2023
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits 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.

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 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
12200 W Colonial Dr Ste 202 · (407) 395-9990 · Call to confirm hours
Pharmacy
736 S Dillard St · (407) 656-2604 · Call to confirm hours
Grocery
1081 9th St · (407) 347-5861 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1320 9th St · (407) 614-1860

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.0%8.7%15.4%better
Long-stay residents who lose too much weight8.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.0%4.6%6.5%typical
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 injury3.0%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.8%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.4%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine99.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.8%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control24.1%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table7.4%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.8%94.7%79.4%better
Short-stay residents rehospitalized after admission24.4%26.1%22.6%typical
Short-stay residents with an outpatient ER visit6.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.382.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.321.151.80better

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

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

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

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

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

39.5% 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 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.5%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
34.7%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 34.7% 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 72 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.5%CMS range 29.7–48.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.5–14.010.7%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 discharge34.7%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 discharge40.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge29.2%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 identified96.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%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 worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 3.5–9.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

0.42
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.29
RN hoursweekends
45.7%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.2 residents a day — about 91% occupied, or roughly 11 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.18 hrs/resident/day on weekends vs 3.57 on weekdays — 11% thinner on weekends. RN hours go from 0.48 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-02-07)
6
at the previous standard inspection (2023-06-02)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-21 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services, consistent with professional standards of practice, to ensure safe medication administration for three residents reviewed for anticonvulsant medications, of a total sample of 10 residents, (#1, #2, and #3).Findings:1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (one-sided weakness and paralysis) following a cerebral infarction (stroke), epilepsy, dementia, dysphagia (trouble swallowing) and type 2 diabetes mellitus.Review of a physician progress note on 1/13/26 revealed the resident had an episode of unresponsiveness to voice or light touch and he would only open his eyes to a strong rub on the chest bone. The resident was sent to the hospital for further evaluation.The hospital 'After Visit Summary' dated 1/13/26 to 1/19/26 listed his diagnosis as a breakthrough seizure. Review of the resident's discharge medication…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-04 · 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 observation, interview, and record review, the facility failed to include pressure and surgical wounds as part of Comprehensive Resident Centered Care Plans, for 2 of 3 residents reviewed for wound care, (#1 and #3), of a total sample of 4 residents.Findings:1. Review of the medical record revealed resident #1, a [AGE] year-old female was admitted to the facility on [DATE] from another nursing home and re-admitted from an acute care hospital on [DATE]. The resident's diagnoses included fracture of right femur (hip), dementia, muscle weakness, and pressure ulcer of left lower back. On 11/04/25, the resident was discharged to the hospital for failed surgical repair of the right hip.The most recent Comprehensive admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/07/25 indicated resident #1 had one unhealed stage 2 pressure ulcer that was present upon admission. The Discharge Return Anticipated MDS Assessment with an ARD of 11/04/25 incorrectly documented the resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement revised wound specialist physician's orders for a stage 3 pressure injury for 1 of 3 residents reviewed for pressure wounds, of a total sample of 4 residents, (#1).According to the Centers for Medicare & Medicaid Services (CMS), stage 3 pressure ulcers are described as full thickness tissue loss without bone, tendon, or muscle exposure. Stage 4 pressure ulcers include full thickness tissue loss with exposed bone, tendon, or muscle, (retrieved from cms.gov on [DATE]).Findings: Review of the medical record revealed resident #1, a [AGE] year-old female was admitted to the facility on [DATE] from another nursing home and re-admitted from an acute care hospital on [DATE] after hip fracture surgery. The resident's diagnoses included fracture of right femur (hip), dementia, muscle weakness, and pressure ulcer of left lower back, stage 2. On [DATE], the Wound Care Specialist Physician's Assistant (PA) assessed the resident's pressure wound as 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 before2025-12-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a high fall risk resident received timely post-fall assessment, pain management, and emergency medical intervention in accordance with professional standards of practice and the resident's comprehensive, person-centered care plan for one of four residents reviewed for falls, of a total sample of five residents, (#1).Findings: Review of resident #1's medical record dated 11/11/25 through 11/13/25 revealed she was admitted to the facility from an acute care hospital on [DATE] for short-term rehabilitation. Her diagnoses included Alzheimer's dementia, osteoporosis, chronic kidney disease, and a history of falls. Review of the admission Minimum Data Set assessment dated [DATE] showed the resident had a Brief Interview for Mental Status score of 4 out of 15, indicating severe cognitive impairment. The assessment revealed the resident required supervision and assistance for mobility and transfers. She was identified by the facility as a high fall…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat residents in a dignified and respectful manner for 1 of 6 residents reviewed for resident rights of a total sample of 12 residents, (#5). Findings: Review of resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type 2 diabetes, orthostatic hypotension, and history of falling. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 7/15/25 revealed resident #5 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. Review of the MDS admission assessment with ARD of 7/15/25 revealed it was somewhat important for resident #5 to do things with groups of people and do his favorite activities. On 9/24/25 at 11:00 AM, resident #5 expressed frustration regarding the delivery of his meals. He stated that meals were not always served at the same time and when food arrived, it was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-07 · 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, record review, and interview, the facility failed to determine if potentially hazardous foods were at a safe cold holding temperature prior to distribution. Findings: On 2/07/25 at 11:30 AM, during observation of the lunch trayline, the facility cook initiated taking temperatures of the hot food items on the steam table. At 11:45 AM, the cook stated she had completed taking all of the food holding temperatures and the Certified Dietary Manager (CDM) instructed the staff to start the lunch trayline. There was a small table across from the steam table which had beverages including milk, a potentially hazardous food. Review of the facility's food holding temperature log for February 2025 revealed the cold holding temperature for the milk had not been obtained. Shortly after 11:45 AM, as staff began plating food, the cook acknowledged she had not taken the temperature of the milk. The CDM stated the holding temperature of the milk should have had been taken before the start of the trayline but did not offer any reason as to why it was not done. The cook and the CDM…

    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 · E2025-02-07 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the administration failed to ensure safe water temperatures from 2 of 2 boiler rooms that supplied hot water to all resident areas were adequately monitored and failed to oversee environmental services to ensure resident room repairs were conducted routinely. Findings: On 2/03/25 at 3:15 PM, during an interview with resident #62, she stated the bath water the Certified Nursing Assistant (CNA) brought to her bedside that day from the bathroom was too hot and the CNA had to make it cooler. She could not recall the CNA's name. At 3:25 PM, the hot water from the faucet in the bathroom was felt for temperature, but the water was too hot to hold a hand under the water for more than a few seconds. Later at 5:00 PM, the Maintenance Director was asked to take water temperatures in bathrooms for resident #50 and resident #62. At 5:10 PM, the Maintenance Director arrived with an infrared thermometer and a digital probe thermometer. The Maintenance Director turned on the hot water and after approximately 15 seconds, put the probe under the running hot…

    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 · E2025-02-07 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 maintain a safe environment to protect residents, staff, and the public from potential burns to skin by not monitoring the hot water temperatures for water supplied to all resident rooms from 2 of 2 sets of hot water tanks; failed to maintain walls in a resident room in a sanitary manner, (#62); failed to repair the wall after a water leak under the sink, (#97); and failed to maintain the area around a wall unit air conditioner, leaving open space to the outside, (#97). Findings: 1. On 2/03/25 at 3:15 PM, resident #62 stated the bath water the certified nursing assistant (CNA) brought to her bedside that day from the bathroom was too hot and the CNA had to make it cooler. At 3:25 PM, the hot water faucet in the bathroom was turned on and tested by feel. The water was too hot to hold a hand under it for more than a few seconds. On 02/03/25 at 5:10 PM, the Maintenance Director tested the water temperatures in resident #50's and 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 39 residents, (#93). Findings: Resident #93 was admitted to the facility on [DATE] with diagnoses including heart failure, hyperlipidemia, hypertension, and prostate cancer. On 2/03/25 at 10:10 AM, resident #93 had a tube of drug store brand Multipurpose Antibiotic ointment, on the bedside table. Resident #93 stated he used it for a rash on his right ear and applied it himself a few times a day. Resident #93 picked up the tube and asked that the facility not be told of the tube of ointment as he feared they would take it away from him. On 2/04/25 at 10:30 AM, resident #93's bedside table was observed with Registered Nurse (RN) B, a primary care nurse. The RN reported the resident was not supposed to have medications at bedside and explained she had to ask the physician to put an…

    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 · D2025-02-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure the care plan for activities of daily living (ADL) self-care deficit was revised to accurately reflect the interventions for toileting for 1 of 2 residents reviewed for bowel and bladder incontinence, of a total sample of 39 residents, (#89). Findings: The most recent Annual Minimum Data Set (MDS) assessment for resident #89 was completed on 12/06/24. The Bladder and Bowel Incontinence section indicated the resident was not on a bladder or bowel toileting program and was always incontinent (no episodes of continent voiding or bowel movements). A comparison with the Quarterly MDS completed on 9/06/24 revealed the Bladder and Bowel incontinence section assessment had the same findings. The care plan for resident #89 for ADL self-care deficit for toileting was revised on 12/20/24 with a target date of 3/05/25. The goal was, the resident will maintain and/or improve ADL functioning through next review date. The interventions for toileting indicated the resident needed, extensive assistance of one or two staff to stand…

    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
Show the remaining 14 citations
  • Potential for harm · D2025-02-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADLs) related grooming/personal hygiene for 1 out of 5 residents sampled for ADLs, of a total sample of 39 residents, (#88). Finding: Resident #88 was a non-geriatric age resident who was admitted to the facility on [DATE]. Her diagnoses included Huntington's disease, respiratory failure, neuromuscular dysfunction, and dementia. On Tuesday, 2/04/25, at 3:15 PM, resident #88 was in bed and her legs were unshaven. Resident #88 stated she could make her needs known but had poor memory. She stated she couldn't get out of bed by herself due to her condition. She acknowledged she would like her legs to be shaved but could not recall the last time staff had shaved them. Resident #88's Quarterly Minimum Data Set assessment dated [DATE] indicated she required substantial/maximal assistance with bathing and personal hygiene. Review of resident #88's care plan initiated on 7/15/23 and revised on 2/02/24 noted she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-07 · 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 address an alteration in a resident's skin integrity in a timely manner, for 1 of 4 residents reviewed for skin conditions, of a total sample of 39 sampled residents, (#2). Findings: Review of resident #2's medical record revealed an initial admission date of 10/24/22. The resident's diagnoses included cerebral infarction (stroke), chronic kidney disease (unspecified), and cervicalgia (neck pain). Resident #2's Annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12/15, which indicated mild cognitive impairment. Resident #2's medical record revealed a physician's order dated 6/26/24 for Calamine external lotion with directions to apply to rash on arms topically every eight hours as needed for itching. Review of the resident's weekly skin checks dated 1/11/25 and 1/17/25 indicated scratch marks to legs, right arm and right chest, with order for Calamine lotion for itching. The skin check on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · 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, interview, and record review, the facility failed to ensure infection control practices were followed regarding safe medication administration for 1 of 7 residents sampled for medication administration, of a total sample of 39 residents, (#51). Findings: Resident #51 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus with hyperglycemia. Resident #51 had a physician's order dated 9/24/24 for Humalog Kwikpen Subcutaneous solution pen injector 100U (units)/ml (milliliter) (insulin Lisro) inject subcutaneously before meals and at bedtime per sliding scale for type 2 diabetes mellitus with hyperglycemia. Inject as per sliding scale: if 150-200=1 U, 201-250=2U; 251-300=3U; 301-350= 4U; 351-400= 5U; 401-500= 6 units greater than 500, call physician. Review of the facility provided manufacturer's instructions for use of the Humalog KwikPen insulin injection, revised on 7/20/23, revealed in preparing the pen section step 1 included to wipe the rubber seal with an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an injury resulting in serious bodily harm was reported to the relevant Federal and State Agencies for 1 of 3 residents reviewed for falls, of a total of 10 residents, (#1) Findings: Resident #1, a [AGE] year-old female was admitted to the facility originally on 1/12/21, with her most recent readmission on [DATE]. Her diagnoses included Parkinson's disease, urinary tract infection, acute respiratory failure with hypoxia, generalized muscle weakness, and abnormalities of gait and mobility, and history of falls. Review of the facility's incident log from June 2023 to current revealed the resident had a fall on 9/12/23. A nursing progress note dated 9/12/23 at 9:19 PM, indicated the resident was observed lying on her left side on the floor mat. Resident stated she was trying to get in wheelchair, since her son wants her to walk more. Review of the Change in Condition form dated 9/20/23 revealed the resident was transferred to an acute care…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-02 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 present up-to-date staffing hours for residents and visitors in a complete and accurate format. Findings: On 5/30/23 at 9:55 AM, observations revealed an incomplete daily staffing projection form to the left of the receptionist desk located on the wall across from the staffing office. The form showed no data for hours for Registered Nurses (RN) on the 7 AM to 3 PM (day shift), Licensed Practical Nurses (LPN) or Certified Nursing Assistants (CNA's) in the columns for 11 PM to 7 AM (night shift), 7 AM to 3 PM (day shift) or 3 PM to 11 PM (evening shift). On 5/30/23 at 3:30 PM, observations revealed no hours entered on the posted daily staffing projection form. During review of the daily staffing posting with the Labor/Staffing Coordinator, she explained she had not posted the hours and no one told her they were to be posted. On 5/31/23 at 1:39 PM, review of the 18 months of various daily staffing projection forms with the Labor/Staffing Coordinator noted staffing form dated 5/1/23 with no hours for RNs on the 7…

    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 · D2023-06-02 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge form for 2 of 2 residents reviewed for hospitalization, of a total sample of 58 residents, (#82, #99). Findings: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included diabetes, muscle weakness, chronic kidney disease and heart attack. Review of resident #82's medical record revealed he was emergently hospitalized on [DATE]. A nurse's Progress Note dated 4/13/23 described resident #82 with mental status changes and abnormal vital signs and was sent to the hospital via 911 for a possible stroke by the physician. The medical record did not contain a written Notification of Transfer or Discharge form for the hospitalization. 2. Resident #99 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, heart failure, breast cancer and stroke. Review of resident #99's medical record revealed she was emergently hospitalized on [DATE]. A nurse'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-02 · 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 observation, interview, and record review, the facility failed to develop a comprehensive individualized care plan with interventions to address administration of Continuous Positive Airway Pressure (CPAP) for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90). Findings: On 5/30/23 at 1:45 PM, resident #90 was observed in her room. She was alert and oriented to person, place, and time. She had a CPAP device observed on her bedside table. Resident #90 said she recently became very sick with Corona Virus Disease 2019 (COVID 19) which made her weak and unable to get out of bed. Prior to the infection she was able to walk up and down the halls with her walker. She explained she could not use her CPAP when she became sick. The resident indicated concerns that CPAP equipment had not been cleaned, the mask did not fit properly, and the humidifier reservoir water had not been changed since she had COVID 19. Resident #90 was admitted to the facility from the community on 3/1/22 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 before2023-06-02 · 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 care and services consistent with professional standards of practice pertaining to continuous positive airway pressure (CPAP) for 1 of 3 residents (#90) reviewed for respiratory care, and failed to ensure oxygen concentrator was maintained in a clean manner for 2 of 3 residents (#28, #79) reviewed for respiratory care and failed to provide oxygen rate per physician order for 1 of 3 residents reviewed for respiratory care (#28) of a total of 58 residents. Findings: 1. Resident #90 was admitted to the facility on [DATE] with diagnoses of obstructive sleep apnea, heart failure, neuropathy, diabetes, osteoarthritis left shoulder, age related debility, and recently positive for COVID 19 (Coronavirus Disease 2019) on 5/18/23. A Pulmonary consultation note dated 9/15/22 read, This [AGE] year-old female. History of Present Illness .Telemedicine follow-up for obstructive sleep apnea. Patient's obstructive sleep apnea was diagnosed 8 years…

    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 · D2023-06-02 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 nursing staff received the necessary training for care of residents on continuous positive airway pressure (CPAP) therapy for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90). Findings: Resident #90 was admitted to the facility from the community on 3/1/22 with diagnoses that included obstructive sleep apnea, heart failure, neuropathy, diabetes, osteoarthritis left shoulder, age related debility, and recently positive for Corona Virus Disease 2019 (COVID 19) on 5/18/23. A Pulmonary consultation note dated 9/15/22 read, This [AGE] year-old female. History of Present Illness .Telemedicine follow-up for obstructive sleep apnea. Patient's obstructive sleep apnea was diagnosed 8 years ago .Patient is compliant with CPAP and using it every night .Her CPAP machine is very old, and she needs a new CPAP machine .5/10/22 30-day compliance reported was reviewed with patient. Patient is very compliant 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-02 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure behavior monitoring was initiated and provided for 1 of 5 residents reviewed for Unnecessary Medication Review out of a total sample of 58 residents, (#434). Findings: Review of resident #434's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Anxiety Disorder, Depression and other specified disorders of the brain. Review of the physician's orders dated 05/29/23 documented Trazodone 100 milligrams (mg) orally (po) at hours sleep for major depression, Escitalopram 20 mg po daily for depression, and Buspirone 10 mg po three times a day for anxiety. Review of resident #434's plan of care dated 05/30/23 documented antipsychotic medication use with interventions to monitor/document/report as needed any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, extrapyramidal side effects (EPS) shuffling gait, ridged muscles, shaking, frequent falls,…

    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 before2021-11-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 record review, the facility failed to ensure the dishwashing machine was operating to properly wash and sanitize resident dishware, and failed to ensure sanitizing strips for the 3-compartment sink were not expired. Finding: 1. On 11/02/21 at 10:28 AM, the dishwashing machine revealed a low temperature with the wash temperature at 120°Fahrenheit (F) and rinse at 120°F. The test strip used for the chlorine-based sanitizer was not readable. The wash and rinse water were very sudsy. There was no sanitizer solution present. The Food Service Director (FSD) said that they washed the dishes yesterday with pot and pan soap when the correct soap was not available. She said she had just brought out a bottle of sanitizer. The label read rinse agent. The FSD said that the facility previously had a high temperature dishwashing machine. The machine was changed while she was on vacation. The facility was waiting for a new high temperature dishwashing machine. 11/02/21 at 11:17 AM, the FSD had one test strip for chlorine sanitizer that read 200 parts per million…

    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 · E2021-11-04 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 all dietary staff were trained to operate a temporary dishwashing machine. Findings: On 11/02/21 at 10:28 AM, the dishwashing machine was a low temperature machine. The Wash temperature was 120°F, rinse temperature was 120°F. The water very sudsy. There was no sanitizer present The Food Service Director (FSD) said that they had washed the dishes yesterday with pot and pan soap. The sanitizer did not function properly. The FSD said that the dishwashing machine changed out while she was on vacation. She had always used a high temperature dishwashing machine. She was not trained on how to operate this machine. When asked how the staff were trained to use the temporary machine. She did not have a response. On 11/02/21 at 11:33 AM, the Regional Director of Dietary Service said she would look for the and training procedures for dishwashing, and the orientation checklist. On 11/02/21 at 11:51 AM , the administrator explained, We ordered a new machine, the supplier sent us a temporary machine and a low…

    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 · D2021-11-04 · 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 observation interview and record review, the facility failed to develop a baseline plan of care for 2 of 2 residents reviewed in a total sample of 40 residents (#676 & 677). Findings: 1. Resident #676 was admitted to the facility on [DATE] with muscle weakness falls, myelodysplastic syndrome, cancer and multiple comorbidities. She left the facility and returned on10/28/21. On 11/01/21 at 11:32 AM, she had a left side chest catheter with a sealed covering with tubing extending outside the covering, dated 10/28/21. The resident said that it was used for a chemotherapy treatment for a blood disorder. It was flushed daily when she was in the hospital. The staff at the facility covered it with a plastic bag when she showered but no one changed the sealed dressing. When asked about her plan of care, the resident did not recall an initial care plan in writing but the facility may have had a phone call with a family member. The admission orders entered on 10/27/21 did not include any monitoring of the 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-04 · 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 dispense oxygen as ordered for 2 of 2 residents reviewed for respiratory care in a total sample of 40 residents (#677 & 35). Findings: 1. Resident #677 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease (COPD), anxiety and depression. On 11/01/21 at 11:38 AM, Resident #677 sat in her wheelchair and used oxygen via an oxygen (O2) concentrator. The O2 was set between 1.25 and 1.5 liters per minute (l/min). The resident said, I use two liters per minute at home. Physician orders at 3:30 PM for O2 therapy, dated 10/27/21, was for oxygen at two liters per minute via nasal cannula continuously; monitor every shift for shortness of breath. On 11/01/21 at 3:40 PM, LPN A reviewed the order and verified the O2 should be 2 l/min. Resident #677 room was enetered at 3:43 PM, and LPN A confirmed the oxygen concentrator was set at 1.5 l/min. 2. Resident #35 was admitted on [DATE] with diagnoses including…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASTON HEALTH — 38 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 52.7-0.7 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 37 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Crescent Health And Rehabilitation CenterSarasota, FL 1 of 5Kensington Gardens Rehab And Nursing CenterClearwater, FL 1 of 5Nursing & Rehabilitation Center Of New Port RicheyNew Port Richey, FL 1 of 5Oak Haven Rehab And Nursing CenterAuburndale, FL 1 of 5Vero Beach Care CenterVero Beach, FL 2 of 5Baya Pointe Nursing And Rehabilitation CenterLake City, FL 2 of 5Capri Health And Rehabilitation CenterVenice, FL 2 of 5Creekside Health And Rehabilitation CenterSarasota, FL 2 of 5Fairway Oaks CenterTampa, FL 2 of 5Flagler Health And Rehabilitation CenterBunnell, FL 2 of 5Haines City Rehabilitation And Nursing CenterHaines City, FL 2 of 5Highlands Lake CenterLakeland, FL 2 of 5Indian River CenterWest Melbourne, FL 2 of 5North Port Rehabilitation And Nursing CenterNorth Port, FL 2 of 5Pensacola Nursing & Rehabilitation CenterPensacola, FL 2 of 5Riverwood CenterJacksonville, FL 2 of 5Sandgate Gardens Rehab And Nursing CenterFort Pierce, FL 2 of 5Sea Breeze Rehab And Nursing CenterVero Beach, FL 2 of 5Tierra Pines CenterLargo, FL 2 of 5Viera Del Mar Health And Rehabilitation CenterViera, FL 3 of 5Cedarbrook Health And Rehabilitation CenterFort Myers, FL 3 of 5Coquina CenterOrmond Beach, FL 3 of 5Eagleridge Health And Rehabilitation CenterFort Myers, FL 3 of 5Fouraker Hills Rehab And Nursing CenterJacksonville, FL 3 of 5Hillside Health And Rehabilitation CenterZephyrhills, FL 3 of 5Oakpark Health And Rehabilitation CenterPalm Harbor, FL 4 of 5Bridgeview CenterOrmond Beach, FL 4 of 5Coastal Health And Rehabilitation CenterDaytona Beach, FL 4 of 5Debary Health And Rehabilitation CenterDebary, FL 4 of 5Fernandina Beach Rehabilitation And Nursing CenterFernandina Beach, FL 4 of 5Island Lake CenterLongwood, FL 4 of 5Meadowpark Health And Rehabilitation CenterDunedin, FL 4 of 5Parkside Health And Rehabilitation CenterDeland, FL 4 of 5Ruleme CenterEustis, FL 4 of 5Seaside Health And Rehabilitation CenterDaytona Beach, FL 5 of 5Bayview CenterEustis, FL 5 of 5Osprey Point Nursing CenterBushnell, 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
WG REHAB HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/03/2018
QUALITY REHAB PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 08/01/2019
WILDES, DONNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
BRITTON, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
JACK, ALECIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2025
RICHARDSON, NEEMAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/25/2023
THOMAS, CHANAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/29/2024
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$13.1M
Net patient revenuemost recent cost report
+4.8%
Operating marginrevenue minus expenses
$2.0M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 10%Other / private 35%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$310per resident / day
operating cost
$9,429per month
≈ monthly operating cost
$326per 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 105518. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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