Winter Haven Health And Rehabilitation Center
202 Ave O NE, Winter Haven, FL 33880 · Non profit - Corporation · 140 certified beds · (863) 293-3103 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,190 in federal fines (most recent 2024-01-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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.
| 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.5% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.1% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.9% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 4.1% | 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 table | 19.0% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.9% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.51 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.85 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
39.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.9% 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 69 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.3%CMS range 24.3–53.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.3–16.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 60.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 55.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 92.7% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 98.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.8%CMS range 5.8–16.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 140 beds and averages 134.5 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.15 hrs/resident/day on weekends vs 3.25 on weekdays — 3% thinner on weekends. RN hours go from 0.69 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2024-10-28 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure care for gastrostomy tubes was provided in accordance with professional standards for one (#2) of three residents sampled for gastrostomy tubes. Findings included: A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of intestinal obstruction. Resident #2 was discharged from the facility on 8/24/2024. A review of Resident #2's physician orders revealed the following orders: - An order dated 8/11/2024 indicating Resident #2's gastrostomy tube (GT) site may be left open to air if clean and no drainage and to monitor for skin integrity and changes every shift. - An order dated 8/14/2024 to evaluate for displacement of the GT every shift by observing for abdominal distension, nausea, vomiting, and pain. If displacement is suspected, clamp GT and call the physician. A review of Resident #2's Treatment Administration Record (TAR) for August 2024 revealed the following: - Monitoring 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.
- Potential for harm · Ecited before2024-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a clean, sanitary, and homelike environment for residents on one unit (#300) out of three units in the facility. Findings included: An observation was conducted on 1/21/24 at 10:19 a.m. of room [ROOM NUMBER]. The observation revealed a three-drawer dresser inside the bathroom with a missing drawer and on the floor next to the dresser was 2 gray water basins sitting on the floor. The over-bed table of the room was rusty and uncleanable. The vinyl baseboard near the closet was missing and the wallboard was broken. The wall near the entrance door was broken behind the baseboard. An observation on 1/21/24 at 10:45 a.m., was made of room [ROOM NUMBER]. An open area of approximately 3/4 inch was noted on the side of the wall air conditioning unit. The area was open to the outside and could be seen while standing in the resident room. The closet door track was rusty and unclean. An over-the-bed table located in the room was rusty 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.
- Potential for harm · E2024-01-24 · tag F0644 — patternCoordinate 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 interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four residents (#51, #236, #72, #115) out of six sampled residents, were revised for accuracy related to diagnoses. Findings included: 1) A review of Resident #51's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The record showed diagnoses of unspecified Alzheimer's disease with an onset date of 8/3/21, unspecified dementia unspecified severity with other behavioral disturbance, mild single episode major depressive disorder, delusional disorders, and other insomnia. Review on 1/22/24 at 9:51 a.m., of Resident #51's admission Record showed Alzheimer's disease was the primary diagnosis. Review of Resident #51's PASRR, dated 3/16/23, showed the resident had a mental illness (MI) of depressive disorder and did not reveal the resident's delusional disorder. The PASRR did not reveal the resident had a primary diagnosis of dementia or related…
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.
- Potential for harm · E2024-01-24 · tag F0645 — patternPASARR 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 interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment for a qualifying mental health diagnosis for two residents (#6 and #97) of six residents sampled. Findings included: Review of the admission Record showed Resident #6 was admitted on [DATE], and readmitted on [DATE], with diagnoses of dementia without behavioral disturbance, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, mood disorder, and other comorbidities. Review of Resident #6's PASRR Level I Assessment, dated 02/24/2023, showed a qualifying mental health diagnosis marked in section I A. for anxiety. Section II, (7) is marked yes for having validating documentation to support the dementia . and documentation should accompany the Level I PASRR screen . There is no evidence a Level II evaluation was submitted. During an interview on 01/22/2024 at 04:11 PM, the Social Service Director (SSD) confirmed responsibility for the completion 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.
- Potential for harm · Ecited before2024-01-24 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 failed to provide treatments and care in accordance with professional standards of practice as evidence by 1) failure to assess and treat a wound for one resident (#51) out of two sampled for skin conditions, 2) failure to document and treat a change in condition according to facility policy for one resident (#82) out of two residents sampled for change in condition, and 3) failure to maintain a midline intravenous catheter as ordered for one resident (#41) out of one sampled for intravenous access. Findings included: 1) On 1/21/24 at approximately 10:18 a.m., Resident #51 was observed sitting across from the nursing station of the secured unit with other residents. The observation showed a brown adhesive dressing on the left toe. The dressing appeared to be undated. On 1/21/24 at 10:22 a.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) placed blue non-slip socks on Resident #51. The staff member reported not knowing why 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.
- Potential for harm · E2024-01-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure hydration was provided to residents residing on the secured unit in a sanitary manner during two lunch meals (1/21/24 and 1/22/24) out of two lunch meal observed. Findings included: On 1/21/24 at 12:43 p.m. a meal cart was delivered to the 300-hall. On 1/21/24 at 12:48 p.m., Staff K, CNA, removed a tray of pre-filled uncovered cups of three different colored liquids from the second shelf of a three shelf cart and placed the tray onto the top of the meal cart. The staff member stated the cups were pre-filled on the unit. On 1/21/24 at 12:55 p.m. an observation was made of the meal cart on 300-hall moving from between rooms [ROOM NUMBERS] to outside of room [ROOM NUMBER] with the same above mentioned pre-filled uncovered cups on top. Staff were observed removing trays from the cart then placing the pre-filled cups on the tray before delivering to resident rooms. (Photographic evidence was obtained). On 1/22/24 at 12:35 p.m. 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.
- Potential for harm · D2024-01-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 failed to provide one resident (#109) with dignity and respect related to bowel and bladder needs out of one resident sampled for dignity. Findings included: On 01/22/24 at 9:30 a.m. an interview was conducted with Resident #109. The resident stated he had been in the facility for about two months for rehabilitation after suffering a fractured hip. He stated he had limited weight bearing abilities. He stated he used a urinal due to his limited abilities. Two urinals were observed at the bedside. Resident #109 appeared embarrassed to admit he has to have assistance with toileting. On 01/23/2024 at 9:29 a.m. Resident #109 was observed lying in bed. The resident stated he was waiting for a care giver to provide assistance following a bowel movement. Resident #109 stated his brief was dirty because he cannot use the bed pan. He stated the bed pans are too small for him to use and he was embarrassed when staff have to clean his bottom after having 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.
- Potential for harm · D2024-01-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one resident (#82) of five residents sampled for comprehensive care plans. Findings included: A review of Resident #82's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record showed diagnoses not limited to not elsewhere classified anoxic brain damage, unspecified intractable epilepsy with status epilepticus, and adult failure to thrive. A review of Resident #82's medical record showed a completed Hospital Transfer Form dated 1/19/24. The form showed the reason for transfer was the Replacement of G-tube. The form revealed the resident was sent to an acute care hospital on 1/19/24. On 1/23/24 at 1:49 p.m. Resident #82 was observed lying in bed, bilateral legs were contracted at bilateral knees, hands held near the head region, and the resident remained nonverbal but followed this writer and Staff C, Registered…
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.
- Potential for harm · D2024-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide activities of daily living (ADL) for one resident (#18) out of four residents sampled for ADL care related to personal hygiene and bathing. Findings included: 1) An observation on 01/21/24 at 11:05 AM revealed Resident #18 lying in his bed. The resident was able to verbalize his name and introduce himself. Closer observation of the resident revealed the resident was noted with stubbly white facial hair and long fingernails. The resident was asked if he preferred facial hair and he stated, No, I need a shave, you gonna shave me? An observation of Resident #18 on 01/22/24 at 10:07 AM revealed the resident resting in bed. The resident was noted with his face still unshaven with gray stubbly hair covering his face and chin. The resident's fingernails were noted to still be elongated on his bilateral hands. The resident reported he was still waiting to be shaved and does not like the hair on his face and would like for his nails to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide care and services according to physician's orders related to catheter care for one resident (Resident #36) out of the two sampled residents. Findings included: On 01/21/24 at 10:10 a.m., the resident was observed in bed in his room. There was a foul urine smell in the room. Resident #36 was verbal but was not able to answer questions appropriately during an attempt to interview him. A review of the admission Record for Resident #36 showed he was admitted on [DATE] with diagnosis of personal history of urinary tract infection and neuromuscular dysfunction of bladder. Section C: Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating severe cognitive impairment. Section H: Bladder and Bowel showed the resident had an indwelling catheter. The Order Summary Report with active orders as of 11/01/23 revealed the following:…
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.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-01-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 5.00%. Twenty-nine medication administration opportunities were observed and two errors were identified for one resident (#55) of four residents observed. These errors constituted a 6.9% medication error rate. Findings included: 1) On 1/23/24 at 8:43 a.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #55. The staff member dispensed the following medications: - Carvedilol 25 milligram (mg) tablet - Docusate sodium 100 mg over-the-counter (OTC) geltab - Eliquis 2.5 mg tablet - Lactulose 10 g/15mL (gram/milliliter) liquid - poured 15 mL's into medication cup - Minoxidil 10 mg tablet - Renavite OTC tablet - Sevelamer Carbonate 800 mg tablet Staff I, LPN confirmed dispensing 6 tablets and one liquid medication for Resident #55 prior to entering the resident room and administering the medications. Review of Resident #55's January 2024 physician orders and Medication Administration Record…
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.
- Potential for harm · Dcited before2024-01-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interviews and record review the facility failed to ensure all medications were secured appropriately limiting access to unauthorized persons 1) in one treatment cart (100 hall) of 3 treatment carts, and 2) leaving medications unsecured during medication administration. Findings included: 1) During the initial tour of the facility on 01/21/24 at 09:13 AM, observations of the 100 hall revealed a treatment cart labeled 100 hall treatment cart. Closer observations of the treatment cart revealed the lock button on the cart was fully extended exposing the red lock area. An attempt to open drawers on the treatment cart was successful revealing multiple residents topical medication stored in the lower draw. (Photographic evidence obtained). Continued observations at this time revealed there were no staff or authorized persons monitoring the treatment cart. An interview on 01/21/24 at 09:14 AM with Staff H, Licensed Practical Nurse (LPN) revealed only she and one other person had the keys to 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.
- Potential for harm · D2024-01-24 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews the facility failed to update the facility-wide assessment to determine what staff competencies are needed for care of residents with different types of acuities. Findings included: Observations made during the survey between 1/20/2024 to 1/24/2024 revealed the facility had residents with indwelling catheters, tracheotomies, intravenous lines, and wounds. These acuities are listed on the Facility Assessments. Review of the Facility Assessment (FA), dated 10/3/2023, showed the resident population, emergency plans, facility description, and type of conditions and acuity the facility cares for. The section titled Disease/Conditions; Physical Disabilities; Cognitive disabilities; Psychiatric Diagnosis; and Acuity. Several columns are at the top of the sections indicating if the resident is admitted - yes, no; if special equipment needs - yes, no, N/A (not applicable); equipment needed; Competency Required - Yes, No, N/A. The Physical Disabilities section is the only section completed for equipment needed and marked yes for staff competency. All…
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.
- Potential for harm · E2021-10-22 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to have an adequate supply of personal care supplies (urinals) for one (Resident #46) out of twenty-seven sampled residents. Findings included: On 10/21/21 starting at 10:00 a.m., a Resident Council Meeting was conducted in the Activities Room. During the meeting, the residents were asked if they had any concerns. Resident #46 stated that they were always running out of urinals. He stated that housekeeping would clean the urinal and return the urinal to him and that was unsanitary. A record review of the admission Record for Resident #46 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction. Section C- Cognitive Patterns of the annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that he was cognitively intact. On 10/22/21 at 1:45 p.m., 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.
- Potential for harm · Ecited before2021-10-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure an adequate supply of linens (towels) for eight (Residents #46, #102, #23, #70, #62, #2, #29, and #107) out of the sampled fifty-seven residents. Findings included: 1. On 10/21/21, starting at 10:00 a.m., a Resident Council Meeting was conducted in the Activities Room. Five (Residents #46, #102, #23, #70, and #62) of the ten residents that attended the meeting reported that they were always running out of towels. They reported that sometimes they were given pillowcases and sheets to dry off with after a shower or bed bath. The residents reported that the washing machines and dryers were always broken. The residents stated that the Certified Nursing Assistants (CNAs) were always going from room to room looking for towels. A record review of the admission Record for Resident #46 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction.…
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.
- Potential for harm · E2021-10-22 · tag F0585 — failed to handle grievances — patternHonor 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 record reviews and interviews, the facility failed to resolve grievances related to cold food for five (Residents #46, #102, #23, #70, and #62) out of fifty-seven sampled residents. Findings included: A review of the Activities Resident Council Minutes dated 08/30/21 revealed that Resident #46 verbalized that the food was cold. The resolution revealed that the Dietary Manager explained that it might be related to the distance from the kitchen to the location of Resident #46's room. She verbalized that she would conduct a test run to make improvements with the food temperature. A review of the Activities Resident Council Minutes dated 09/09/21, revealed that the majority of the meeting was spent on dietary related issues such as chicken served too often and food over or under cooked. The solution indicated that the Dietary Manager explained to the residents that she would review the menu and check with corporate about changes to the menu. She also told the residents that she would let them know what type…
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.
- Potential for harm · D2021-10-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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, interviews, and record review, the facility failed to ensure side effects and/or behavioral monitoring with the use of psychotropic medications for two (Resident #43 and Resident #98) of five sampled residents. Findings include: On 10/20/21 at 10:43 a.m., Resident #43 was observed seated in her room in a wheelchair. Resident #43 was able to answer questions related to care and services in the facility. The resident stated she had been in the facility for several months. The resident appeared clean, dry and had no signs of distress or unusual behaviors noted during the interview. Resident #43 stated she was very sick with COVID last year and that started her decline. On 10/21/21 at 1:00 p.m., Resident #43 was observed in room resting quietly. The resident had no signs of distress, and no behaviors were observed. A review of the medical record for Resident #43 indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety and major depressive disorder. 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.
- Potential for harm · Dcited before2021-10-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, record review, and interview, the facility did not ensure a medication error rate of less than 5%. During the medication pass observation, there were twenty five opportunities with six errors resulting in a 24% medication error rate for two (Residents #63 and #35) of five residents observed. Findings included: On 10/21/21 at 9:00 a.m. medication administration was observed with Staff A, RN with Resident #63. The resident had an order for [brand name] Lidocaine Patch 4% apply to bilateral knees topically one time a day for non-acute pain. The nurse applied the patch to the residents lower back. On 10/21/21 at 9:13 a.m. Staff A, RN passed medications to Resident #35. The resident had current orders for and was given the following medications: Cinacalcet give 30 mg (milligrams) by mouth one time a day for nutritional support Ferrous Sulfate 325 mg give 1 tablet by mouth one time a day for nutritional supplementation Furosemide Tablet give 40 mg by mouth one time a day for edema Hydralazine tablet 10 mg give 1 tablet by mouth three times a day for HTN…
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.
- Potential for harm · Dcited before2021-10-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility did not ensure that a refrigerated controlled substance was secured in a separately locked, permanently affixed container on one of three units. Findings included: On 10/21/21 at 4:29 p.m., Staff B LPN (Licensed Practical Nurse), entered the medication storage room on Unit 1 to get a medication from the refrigerated emergency drug kit (EDK). He pulled out an opaque plastic container with a clear top that measured approximately 7-inches by 11-inches from the refrigerator. On top of this plastic container, attached to one of the corners by hook and loop fastener tape, was a small clear plastic container about the size of a pack of playing cards. When the nurse was asked what the small clear plastic container had in it, and he said Ativan (Lorazepam). Staff B, LPN was asked to count how many vials of medication was in the small clear plastic container, and he answered four . Upon further inspection, it was noted that 4-2 ml vials of Lorazepam were inside of the small clear plastic container. Staff B, LPN confirmed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-22 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of meals, interview with residents and facility staff, and review of the facility's menu and materials on the facility's new diet, ( IDDSI - International Dysphagia Diet Standardization Initiative), the facility failed to ensure residents who were on mechanically altered diets received foods that had been correctly prepared to follow the IDDSI guidelines and ensure the foods were safe for two (Residents #60 and #22) of 41 residents identified as having physician orders for mechanically altered diets. Findings included: 1- On 10/19/2021 at 12:30 p.m., Resident # 60 was observed at lunch. She was observed to be sitting up in bed, with her over the bed table across her waist and her lunch tray accessible in front of her. She had been served a total of three, two scoops of fried rice with pork, broccoli and a wheat roll. The resident had inserted her fork into her roll and was holding the roll up like a flag. The roll looked to be a solid mass and was stable on the tines of the fork. When asked if she needed a knife to cut off a bite of it, she shook her head no…
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.
- Potential for harm · Dcited before2020-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure one ( #4) of 4 residents sampled, received treatment and care in accordance with professional standards of practice related to follow up for low blood pressure readings. Findings included: Observation of Resident #4 on 2/4/20 at 10:46 a.m. reflected the resident sitting up in bed on an air mattress with bilateral floor mats down. The resident's Foley catheter was observed draining dark yellow urine. Tube feeding infusing at 65 cc hour of isosource 1.5 calorie. Resident #4's lips were observed white and dry appearing. A wound vacuum was observed on the resident with small amounts of blood observed moving through the tubing. Review of the medical record revealed a blood pressure dated 12/29/19 at 5:53 a.m. of 76/29. Review of the progress notes did not reflect physician notification or evaluation of the resident. Review of the medical record revealed a blood pressure dated 12/30/19 at 6:27 a.m. of 101/21. Review of the nursing progress note dated 12/30/19 at 6:00 p.m. reflected the resident lying in bed…
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.
- Potential for harm · Dcited before2020-02-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure appropriate treatment and services were provided to prevent urinary tract infections (UTI) for two residents (#76 and #102) of three residents sampled for UTIs. Findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses of sepsis, chronic kidney disease, urinary tract infection, and obstructive and reflux uropathy. A review of Resident #76's care plan revealed that Resident #76 used a urinary catheter with risk of infection and/or complications related to obstructive uropathy with an intervention to keep the catheter tubing free of kinks. A review of Resident #76's physician's orders revealed an order to observe Resident #76's [indwelling] catheter each shift. Resident #76's physician's orders also revealed an order to drain Resident #76's catheter bag every shift and as needed. An interview was conducted on 02/05/20 at 10:34 a.m. with Resident #76 regarding care at the facility. Resident #76 stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-07 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to ensure ongoing communication between the facility and the dialysis care center for one resident (#184) of one sampled resident of a total of three residents who received dialysis care and services. Findings included: Resident #184 was admitted to the facility on [DATE] with a diagnosis of hypertensive chronic kidney disease with stage 5 end stage renal disease. A review of the medical record revealed physician orders for: Dialysis arterial-venous (AV) shunt monitor every shift for bruit and thrill shunt is located at left arm; Epogen to be given at dialysis center during dialysis and Resident to have dialysis on days Tuesday/Thursday/Saturday at dialysis center. A review of the comprehensive care plan for Resident #184 initiated on 1/22/20 revealed the following focus area: Focus: Resident #184 has renal failure and is on hemodialysis. At risk for infection at venous access: Arteriovenous Fistula (AVF) Goal: Will have no untreated…
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.
- Potential for harm · Dcited before2020-02-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 review and interviews the facility failed to ensure that medications were delivered as prescribed for one resident (#120) of eight sampled residents. This resulted in medications being administered crushed in a manner that was not recommended by the manufacturer for Resident #120. These 2 errors observed during the medication administration of 25 total medications represented an error rate of 8.0%. Findings included: Resident #120 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, essential hypertension, type 2 diabetes mellitus, dementia, hypokalemia, peripheral vascular disease and hyperlipidemia. A review of the medical record revealed current medication orders as of February 2020 for Amlodipine Besylate tablet 5 Milligram (mg) tablet one time a day, Aspirin 81 mg tablet one time a day, Baclofen 5 mg tablet two times a day, Chlorthalidone 25 mg tablet one time a day, Gabapentin 400 mg capsule three times a day, Metformin Hydrochloride 500 mg tablet two…
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.
- Potential for harm · D2020-02-07 · tag F0770 — failed to provide lab services — isolatedProvide 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
Based on observation, interview and record review, the facility failed to ensure one (#4) of 4 sampled residents, received laboratory services as ordered. Findings included: During a phone interview on 2/07/20 at 11:05 a.m. with Resident #4's daughter, she stated her father had been at the facility for a while and that she is in communication with the facility. The daughter stated her father was currently hospitalized with a low blood pressure, slight fever and elevated white blood count (WBC) and has a bad history of Methicillin resistant staphylococcus aureus (MRSA). The daughter confirmed he was improving after an IV with antibiotics. Review of hospital emergency department rapid triage documentation dated 2/6/20 at 10:02 a.m. revealed, resident presented blood pressure of 90/39, temperature 99.1, pulse 82. Emergency department pre arrival summary - Needs sternal rub, altered mental status. Dilaudid 6 p.m. and 6 a.m. and Percocet at midnight and 6 a.m. Review of the ARNP progress notes dated 1/20/20 reflected Resident #4 recently sent to the hospital for sepsis evaluation. Review…
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.
“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.
- 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.
Fines & penalties
$4,190 in federal fines across 1 penalty.
- $4,190 — penalty dated 2024-01-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SENIOR HEALTH SOUTH — 8 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 7 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SENIOR HEALTH SOUTH EX LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 07/08/2025 |
| SENIOR HEALTH PROPERTIES SOUTH, INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/30/2000 |
| OMEGA HEALTHCARE INVESTORS, INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 09/01/2005 |
| DEPIANO, RICH | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| JAFFE, HOWARD | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| MULLEN, ANN | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| RICHMOND, PENNY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2025 |
| ELEUS HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/18/2025 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2025 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/06/2012 |
| BROWN, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2019 |
| ROBINSON-BRADY, ALEXIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2019 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 22 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $174K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 105176. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-01-24, 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 →
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