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Life Care Center Of Winter Haven

1510 Cypress Gardens Blvd, Winter Haven, FL 33884 · For profit - Corporation · 177 certified beds · (863) 318-8646 Medicare & Medicaid certified

Call the home — (863) 318-8646 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • a high number of inspection citations overall (22) — 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
  • about 24% of its spending goes to commonly-owned related companies

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 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
400 Avenue K SE · (863) 299-3210 · Call to confirm hours
Pharmacy
970 CYPRESS GARDENS BLVD. · (863) 294-3138 · Call to confirm hours
Grocery
757 Cypress Gardens Blvd · (863) 229-7325 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1800 Cypress Gardens Blvd

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 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.5%8.7%15.4%better
Long-stay residents who lose too much weight5.1%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.1%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
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 injury4.6%2.5%3.3%worse
Long-stay residents whose ability to walk worsened8.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.6%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.5%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control1.9%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table13.1%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.1%94.7%79.4%better
Short-stay residents rehospitalized after admission28.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days3.222.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.331.151.80better

* 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.

57.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 365 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.5%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
77.7%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 77.7% 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 184 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF57.5%CMS range 51.3–61.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 7.5–11.910.7%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 discharge77.7%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 discharge68.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge78.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 setting99.0%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 stay0.7%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 worsened0.7%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 hospitalization8.7%CMS range 5.0–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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
0.85
LPN hours/ resident / day
2.31
Aide hours/ resident / day
3.80
Total nurse hours/ resident / day
0.48
RN hoursweekends
39.0%
Total nursing turnover
46.7%
RN turnover

How full it usually is: this home is certified for 177 beds and averages 168.1 residents a day — about 95% occupied, or roughly 9 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 3.80 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 2.31 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 3.45 hrs/resident/day on weekends vs 3.94 on weekdays — 12% thinner on weekends. RN hours go from 0.69 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-02-20)
6
at the previous standard inspection (2023-01-26)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-02-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were provided dining services and resident care with dignity for four residents (#63, #2, #26, and #72 ) out of eight sampled residents. Findings Include: 1. During an observation made on 02/17/25 at 1:03 pm., Resident #63 was sitting up in bed with her lunch tray placed in front of her. She was observed having a hard time picking up her food using a specialized spoon. At 1:42 p.m., Staff D, Certified Nursing Assistance, CNA was observed standing over Resident #63 assisting her with her meal. During an observation made on 02/19/2025 at 1:29 pm, Resident #63 was observed sitting up in her bed with her lunch tray in front of her. Staff D, CNA was observed standing over her assisting Resident #63 with her meal. Review of an admission Record dated 02/20/2025 showed Resident #63 was admitted to the facility originally on 7/1/2024 and readmitted on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis…

    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 · E2025-02-20 · tag F0687 — failed to care for feet properly — pattern
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide proper foot care and treatment to maintain good foot health according to professional standards of practice for three residents ( #134, #141, and #140) out of fifty-three residents sampled. Findings Include: 1. During an observation on 02/17/2025 at 9:20 a.m., Resident #134 was observed lying down in bed dressed in his night clothes. Resident #134's great toe was observed with the toe nail sticking out of a hole on his left sock. Resident #134 stated he really needed his toenails cut because they were causing his feet to hurt. He stated he had asked staff repeatedly to cut his toenails, but no one would listen to him. Resident # 134 gave consent to take a picture of his toenails. Photographic evidence obtained. During an observation on 02/18/2025 at 3:00 p.m., Resident #134 was observed lying down in bed dressed in his night gown. He stated he had requested to have his toenails and his fingernails cut but staff would not assist…

    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 before2025-02-20 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed, and fourteen errors were identified for six (#143, #37, #218, #117, #120, and #106) of eight residents observed. These errors constituted a 42.42% medication error rate. Findings included: 1. On 2/18/25 at 9:54 a.m. Staff B, Licensed Practical Nurse (LPN) obtained a blood pressure of 115/49 from Resident #143 and informed the resident that the blood pressure medication Hydralazine was going to be held for a while. On 2/18/25 at 9:58 a.m., an observation was made of Staff B dispensing the following medications for Resident #143: - Aspirin Enteric coated 81 milligram (mg) over-the-counter (otc) tablet - Magnesium oxide 400 mg otc tablet - Ferrous Sulfate 325 mg otc tablet The staff member confirmed dispensing 3 tablets for Resident #143, placed the tablets into a plastic envelope and crushed the tablets before placing the remnants into chocolate pudding. Staff B entered the resident's room 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · 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, record review, and interview, the facility failed to ensure two (#49 and #141) of fifty- four sampled residents were assessed for self-administration of medications and failed to ensure physician orders had been obtained for medications observed on over-bed table of one (#141) of two residents observed. Findings included: 1. On 2/17/25 at 12:12 p.m., Resident #49 was observed speaking with a visitor while holding onto a nebulizer device. The observation showed the visitor leave the resident's room on 2/17/25 at 12:14 p.m. Resident #49 leaned over, turned on the nebulizer machine located on the bedside dresser, and put the nebulizer device to her mouth. The observation showed an aerosol-like mist coming from the end of the device. Review of Resident #49's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance and chronic obstructive pulmonary…

    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 · D2025-02-20 · 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 observation, record review and interview, the facility failed to file a grievance related to missing clothes for one resident (#57) out of eight residents sampled. Findings include: During an observation on 2/17/2025 at 9:00 a.m., and 12:00 p.m., Resident #57 was observed sitting on the side of her bed, fully dressed. She stated she had complained to the facility about her missing clothes, and nothing had been done about it. Resident #57 stated no one at the facility told her about the grievance process. Review of an admission Record dated 2/20/2025 showed Resident #57 was admitted to the facility originally on 5/3/2024 and readmitted on [DATE] with diagnoses to include but not limited to other specified fractures of left pubis, subsequent encounter for fracture with routine healing, pain in left hip. Review of a Minimum Data Set, dated [DATE] showed Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. During an interview conducted on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · 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

    Based on record review and interview the facility failed to provide written notification to the resident and resident representative prior to an emergency transfer for one (#49) of two residents sampled for transfer and discharge rights. Findings included: Review of Resident #49's admission record revealed an initial admission date of 1/24/24, a transfer to the hospital on 1/30/25 and a readmission to the facility on 2/5/25. The admission record showed the resident was his own responsible party, and a family member was listed as the first emergency contact. A change in condition evaluation, dated 2/18/25, showed the resident had a large abscess to the left neck area and was having a slight issue with swallowing. An electronic transfer form dated 2/18/25 at 2:19 p.m. showed the resident was transferred to an acute care facility/hospital. Review of Resident #49's electronic record on 2/19/25 revealed no evidence of a written notice of transfer/discharge to the hospital to the resident for the 2/18/25 emergency hospitalization. An interview on 2/19/25 at 12:40 p.m. with the Executive…

    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 · D2025-02-20 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Preadmission Screening and Record Review (PASSR) was completed accurately for eleven residents (#112, #144, #21, #12, #126, #140, #130, #23, #54, #18, and #49) out of 33 residents sampled. Findings included: 1. Review of the admission Record for Resident #112 showed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, altered mental status (unspecified), and cognitive communication deficit. Review of Resident #112's most current Level 1 PASRR was dated 02/14/2023 revealed the PASRR did not show a diagnosis of dementia. Review of a physician progress noted dated 08/11/2024 revealed Resident #112 had a diagnosis of dementia. Review of a physician progress noted dated 11/22/2024 revealed Resident #112 had a diagnosis of dementia. Review of a physician progress noted dated 02/10/2025 revealed Resident #112 had a diagnosis of dementia. Review of Resident #112'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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound care in accordance with professional standards of practice and as ordered by the physician for one resident (#54) of two residents reviewed. Findings included: On 2/17/25 at 2:15 p.m., Staff H, Registered Nurse (RN) removed Resident #54's left foot covering. There were no dressings covering the medial and lateral foot wounds. Staff H checked the resident's footwear for bandages, none were found and said the dressings would be replaced immediately. Review of the admission record showed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes mellitus, and disorder of the skin and subcutaneous tissue. Review of care plan for Resident #54, initiated 12/18/18 showed: Focus-A diagnosis of Diabetes Mellitus; Goal- no complications related to diabetes; Interventions to include- check all of body for skin breaks and treat promptly as ordered by the doctor. Another care plan…

    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 · D2025-02-20 · 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, record review, and interview, the facility failed to obtain physician ordered laboratory testing for one (#141) of fifty-four sampled residents. Findings included: On 2/17/25 at 10:31 a.m. Resident #141 was observed lying in bed. The resident reported being woken up at 4 a.m. to give pills. Review of Resident #141's admission Record showed the resident was admitted on [DATE] with a diagnosis of unspecified hypothyroidism. Review of Resident #141's January and February Medication Administration Records (MAR) revealed the resident was receiving Levothyroxine sodium 100 microgram (mcg) daily for hypothyroidism. The medication was scheduled for 6:00 a.m. daily. Review of Resident #141's January Treatment Administration Record (TAR) revealed an order dated 1/6/25 for Thyroid-Stimulating Hormone (TSH), Free T4, and Parathyroid Hormone (PTH) to be drawn every night shift. This order was discontinued on 1/21/25. The TAR showed the laboratory testing had been administered (per chart code 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · 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

    Based on observation, and interview, the facility failed to ensure direct care equipment was cleaned in between two (#149 and #218) of eight residents observed during the administration of medications. Findings included: On 2/19/25 at 8:17 a.m., an observation was conducted with Staff N, Licensed Practical Nurse (LPN) of the medication administration for Resident #149. The staff member removed a blood pressure wrist cuff from the bottom drawer of the medication cart and dispensed one 81 milligram (mg) chewable tablet of Aspirin, a half tablet of 20 mg Furosemide, and one 5 mg tablet of Lisinopril. Staff N placed the Lisinopril tablet in a separate medication cup then entered the resident's room. Staff N placed the blood pressure cuff on the resident's left wrist and informed the resident to lay arm on stomach. The staff member reported the first attempt to obtain blood pressure the cuff had registered an error. A second attempt was made with results of 101/48 and the staff member held the resident's Lisinopril. After administering the Aspirin and Furosemide, Staff N left the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · F2023-01-26 · tag F0644 — widespread
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for six (Residents #40, #78, #95, #55, #63 and #94) of seven residents sampled for PASARR Level II. Findings included: 1. A review of the electronic medical record (EMR) revealed Resident #40 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) dated [DATE], showed in section I, Resident #40 was admitted with diagnoses of Depression and Schizophrenia. A review of a quarterly MDS dated [DATE] Section I showed the resident had current diagnoses of Depression and Schizophrenia. Review of Resident #40's PASSAR Level I screen dated 11/24/20 revealed no qualifying mental health diagnosis was indicated and no PASARR Level II was required. A Care plan dated 12/29/22 showed a goal initiated on 06/28/21 indicating the resident had actual risk for behavioral deficits and was combative towards…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 observations, interviews, and record review, the facility did not ensure respiratory equipment was stored in a sanitary manner for six (Resident #40, #118, #14, #51, #49 and #103) of eight residents reviewed for respiratory care. Findings included: 1. During facility tours on 01/23/23 at 9:35 a.m., 01/24/23 at 11:15 a.m. and 01/25/23 at 8:22 a.m., Resident #40 was observed in her room in bed. An oxygen concentrator was noted at the head of her bed. The tubing and cannula were tucked on the handle and hung down to the floor. The tubing and cannula were not bagged. Resident #40 did not respond to the interview. Resident # 40 was admitted to the facility on [DATE]. Review of current physician orders dated 01/25/23 showed the resident did not have orders to administer oxygen. 2. On 01/23/23 at 10:34 a.m., 01/24/23 at 9:15 a.m. and 01/25/23 8:33 a.m., an observation was made of Resident #118's CPAP (continuous positive airway pressure ) device stored on top of a bedside table with the mask and tubing lying…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · 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 review, the facility did not ensure dignity was maintained for two (Residents # 103 and #133) of two residents related to catheter exposure to the public during 3 of 4 days of survey. Photographic evidence was obtained Findings included: 1. During facility tours on 01/23/23 at 10:16 a.m., 01/24/23 at 11:25 a.m., and on 01/25/23 at 08:45 a.m., an observation was made of Resident #103's catheter that was visible from the hallway. Resident # 103 was noted laying on his bed, unaware his catheter was visible to everyone walking down the hallway. The resident's door was wide open and the privacy curtain was pulled to the head of the bed. In an interview with Resident #103 on 01/25/23 at 08:45 a.m., the resident stated he did not know his catheter was visible to passersby in the hallway. The resident stated it was no one's business to see his catheter. Resident #103 said, I'd like it covered. A review of Resident #103's electronic medical record (MAR) showed 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · 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 observations, interviews and record review, the facility did not ensure assessments and treatments were provided for two (Residents #49 and #94) of three residents reviewed for skin conditions. Findings included: 1. On 01/23/23 at 1:30 p.m., Resident #49 was observed with an undated dressing on her upper right arm. The dressing was noted with two small blood spots on the lower end of the dressing. The resident was noted to have another undated dressing on the front of her elbow on the upper right arm. The resident was not able to stretch out her arm. Resident #49 stated she had an incident with staff during a therapy session where her arm was caught on the door. The resident could not verify the timing of the incident. The resident stated since that incident, the dressing on her arm had not been changed. Review of a facility document titled, incident by incident type, dated 07/23/22 to 01/23/23 revealed the incident related to Resident #49's arm injury was not documented. Resident #49 was re-admitted to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure behavioral and side effect monitoring related to the use of psychotropic medication was completed for one (Resident #32) of five residents sampled for unnecessary medication use. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder, and mood disorder. A review of Resident #32's physician's orders revealed an order, dated 1/18/2023 for Lorazepam 0.5 milligrams (mg) by mouth twice a day for anxiety and every 24 hours as needed for anxiety. Resident #32's physician's orders did not reveal orders for monitoring of behaviors or side effects related to use of Lorazepam. An interview was conducted on 1/25/2023 at 12:10 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated Resident #32 was prescribed Lorazepam both as needed and routinely and residents receiving psychotropic medications were monitored for any behavioral…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty nine medication opportunities were observed and two errors were identified for Resident #107 resulting in an error rate of 6.9% Findings included: On 01/24/23 at 9:04 a.m., Staff D Licensed Practical Nurse (LPN) was observed administering medication to Resident #107. Staff D administered the following medications. -Vitamin C D5200 (mg) -Loratadine 10 mg - MVI (reg) 1 tablet -Fluticasone-Salmeterol Aerosol 100-50 micrograms/activation (mcg/act) 2 inhalations -Ferrex 150 -Lisinipril 10 mg -Sildenafil 20 mg -Oxybutynin ER 5 mg Following the medication administration observation, a review of the physician's orders for Resident #107 revealed there was no order for Loratadine 10 mg. The resident had a physician's order dated 09/15/2022 for Cetirizine (Zyrtec) 10 mg by mouth one time a day for allergies. A review of physician's order dated 09/15/2022, revealed an order for Fluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 mcg/act, 1 inhalation,…

    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 · D2021-03-12 · 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, record review, photographic evidence and staff interviews, the facility failed to implement a care planned intervention related to the use of heel protectors for one resident (#15) of 47 sampled residents. Findings included: A medical record review conducted for Resident #15 on 3/09/21 revealed that Resident #15 was re-admitted to the facility on [DATE]. The admission Record indicated Resident #15 had multiple diagnoses that included hemiplegia affecting left non-dominate side, and general muscle weakness. The medical record revealed that Resident #15 had a plan of care with a focus related to the resident being at risk for break in skin integrity. The interventions included, heel protectors to BLE (bilateral lower extremities) while in bed, initiated on 1/20/21. A review of the medical record revealed a physician order dated 1/20/21 at 13:59 (1:59 p.m.) for heel protectors to BLE while in bed every shift. On 3/09/21 at 10:36 a.m. during an attempted interview with Resident #15, as the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility did not monitor specific behaviors for one resident (#84) and did not monitor the side effects of psychotropic medications for one resident (#115) out of five residents sampled for unnecessary medications. Findings included: 1. The pharmacy policy titled, Psychotropic Medication Use, that the facility provided, revised 11/28/16, indicated the policy sets forth procedures relating to psychotropic medication use. The procedure portion of the policy indicated: 1. Facility should comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacological medications including gradual dose reductions. The procedure identified the following: - 4. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms.; - 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-12 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three residents (#3, #44, and #37) of five residents observed. These errors constituted a 14.29% medication error rate. Findings included: 1. On 3/10/21 at 4:08 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) was conducted with Resident #3. Staff A was observed administering the following medications: - Novolog 100 unit/milliliter (u/mL) Flex Pen - 8 units subcutaneously per a blood glucose level of 347. - Hydralazine 50 milligram (mg) orally - Fish Oil 500 mg - 2 capsules - Levemir Insulin pen - 28 units subcutaneously The observation revealed that Staff A, RN dialed the Novolog Flex Pen to 2 units and informed Staff E, Licensed Practical Nurse (LPN), who was orientating, that to prime the pen, dial it to 2 units and wait a minute then…

    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 · D2021-03-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles by not ensuring: 1. one treatment cart (Oasis Suites) was locked while unattended, 2. one comfort kit was discarded timely for a deceased resident in one medication room (Oasis Suites), 3. eye drops with an expiration date was dated when opened on one medication cart (Golden Hall), 4. insulin pens were dated when opened and refrigerated when unopened, and ProSource Plus undated in two medication carts (Oasis Suites Hall and Cypress Hall), and a Victoza pen was stored in the original pharmacy packaging in one medication cart (Oasis Hall) of a total of five treatment carts, seven medication carts and five medication rooms. Findings included: 1. On [DATE] at 11:55 a.m., a treatment cart was observed unlocked and unattended next to the nursing station on the 400-hall, Oasis Suites. Staff B, Licensed Practical Nurse (LPN) was 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-12 · 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

    Based on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety by not ensuring pre-prepped desserts, a peanut butter and jelly sandwich, and a fruit plate with cut melon and grapes were dated, and not ensuring two personal water bottles were not stored in a cooler in the prep area of the kitchen, and that two measuring scoops were not stored in dry good containers. Findings included: On 3/9/21 at 9:27 a.m., a tour of the cooking, cleaning, and storage areas of the kitchen was conducted with the Certified Dietary Manager (CDM). An observation of the reach-in refrigerator located across from the steamer table revealed two cups of an orange whipped dessert on a tray were uncovered and undated. The CDM confirmed the orange whipped desserts and tray were not dated and should be. On the top shelf of the reach-in refrigerator was a peanut butter and jelly sandwich and a fruit plate with cut melon and grapes that were undated. During the tour an observation of the juice/coffee area identified a measuring…

    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 · D2021-03-12 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility's Quality Assurance Committee failed to implement an effective plan of action related to behavior monitoring associated with the use of psychotropic medications for three residents (#6, #5, and #4 ) of three residents sampled. Findings included: A review of the facility's plan of correction for the recertification survey ending on 3/12/21 revealed the following measures would be taken to correct the deficient practice which was identified at F758: the Director of Nursing (DON)/designee was to audit residents receiving psychotropic medications to ensure Behavior Monitoring Flowsheets (BMFs) were initiated, nursing staff were educated in the implementation of BMFs if necessary, and weekly audits by Unit Managers to ensure that BMFs were initiated for those residents receiving psychotropics. The policy titled, Quality Assessment and Assurance Committee Meetings, issued 12/20/19 and reviewed 12/28/20, indicated the purpose was to provide guidance for…

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

    Administration 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 LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.4+0.6 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
MENNEN, SARAHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/20/2025
PRESTON, AARONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
RAWLINSON, PAMELAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/06/2021
FLETCHER, TODDIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
LAY, LISAIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/09/2018
PRESTON, FORRESTIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/1976
SWANKER, RICHARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
ZIEGLER, JAMESIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/16/1999
CROSS, CINDYIndividualCORPORATE OFFICERsince 04/21/1994
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/22/2000
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2000
CARLUCCI, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/07/2025
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/27/2024

CMS files one row per role, so the 31 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$19.5M
Net patient revenuemost recent cost report
+1.5%
Operating marginrevenue minus expenses
$4.6M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 13%Other / private 29%

This home reported $4.6M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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

$318per resident / day
operating cost
$9,674per month
≈ monthly operating cost
$323per 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 105792. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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