Winter Park Care And Rehabilitation
2970 Scarlett Rd, Winter Park, FL 32792 · For profit - Limited Liability company · 103 certified beds · (407) 671-8030 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $73,968 in federal fines (most recent 2024-02-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 21% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 13.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.1% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.4% | 4.6% | 6.5% | better |
| 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 | 3.8% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.1% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.4% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 92.6% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.3% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.60 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.25 | 1.15 | 1.80 | better |
‡ 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.
37.9% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 49 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 37.9%CMS range 23.3–56.2 | 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 | 12.1%CMS range 8.8–17.4 | 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 | 53.1% | 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 | 38.8% | 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 | 51.0% | 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 | 95.8% | 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 | 75.0% | 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 | 4.2% | 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 | 4.2% | 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 | 8.4%CMS range 4.6–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 103 beds and averages 83.4 residents a day — about 81% occupied, or roughly 20 beds typically open. It usually has some room. 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 0.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.00 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.00 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.
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 fewer than at the previous inspection — improving. 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.
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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2024-02-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility neglected to provide appropriate care and services to prevent a fall with major injury for a vulnerable and physically impaired resident, during a transfer with a mechanical lift and failed to complete a thorough investigation after a fall with major injury for 1 of 6 residents sampled for falls, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination 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.
- Immediate jeopardy · J2024-02-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to prevent a fall with major injury for a vulnerable, physically, impaired resident, and failed to ensure the correct procedure was followed when using a mechanical lift to transfer residents for 1 of 6 residents sampled for falls, out of a total sample of 45 residents, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of 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 · Ecited before2025-07-10 · tag F0867 — failed to act on quality-improvement findings — patternSet 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
Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan revealed the facility must take actions aimed at performance improvement and measure its success and track performance to ensure that improvements were realized and sustained. The facility would develop and implement policies addressing how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. The facility had deficiency cited at F641 during the previous recertification survey conducted 2/12/24 to 2/17/24 for accuracy of assessments. During this survey, the facility was found to again be in noncompliance with F641 for accuracy of assessments regarding Minimum Data Set (MDS) assessments. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight 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.
- Potential for harm · D2025-07-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 observation, interview, and record review, the facility failed to ensure an appropriate wheelchair was provided to accommodate the needs and preference of 1 of 1 resident reviewed for resident rights, of a total sample of 30 residents, (#82). Findings:Resident #82 was admitted to the facility from an acute care hospital on 2/24/25 with diagnoses that included wedge compression fracture, history of falls, muscle wasting with atrophy, and need for assistance with personal care. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #82 had a Brief Interview of Mental Status (BIMS) of 15/15 which indicated she was cognitively intact and able to make her needs known. She had no upper or lower limitations in range of motion and utilized a wheelchair for mobility.On 7/07/25 at 11:45 AM, resident #82 was observed in her room sitting up in a transport wheelchair watching television. She stated she was a private person and preferred to do activities in her room but sometimes…
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 before2025-07-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for nutritional approaches for 1 of 3 residents reviewed for nutrition, of a total sample of 30 residents, (#84).Findings:Resident #84 was initially admitted to the facility on [DATE] for strengthening following a hospital stay and a new lymphoma diagnosis. Resident #84 was discharged home with family and hospice services on 6/02/25. On 6/12/25 the resident was readmitted to the facility with generalized weakness and edema. The resident's diagnoses included diffuse large B-cell lymphoma (cancer), muscle wasting and atrophy, urinary tract infection, and stage 2 chronic kidney disease. Review of the admission MDS assessment with Assessment Reference Date of 6/19/25 revealed resident #84's nutritional approaches included parenteral or intravenous (IV) feeding while a resident and a mechanically altered diet which required a change in texture of food or liquids on admission. Under the section…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-10 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV) catheter dressing was changed every seven days per physician order for 1 of 1 resident reviewed for IV therapy, of a total sample of 30 residents, (#142).Findings:Resident #142 was admitted to the facility on [DATE] with diagnoses including fracture of neck, intraspinal abscess and spinal stenosis-cervical region. Review of resident #142's electronic medical record (EMR) revealed a Brief Interview for Mental Status (BIMS) assessment dated [DATE]. The assessment indicated he had a BIMs score of 15/15 which meant he was cognitively intact.A care plan initiated 7/07/25 indicated resident #142 received IV therapy related to antibiotic therapy administration. Interventions included, Observe dressing. Change dressing and record observations of site.Review of resident #142's EMR revealed physician orders were added on 7/07/25 for the care of the IV insertion site. The orders included directions to observe the site…
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 · D2024-10-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had an accurate medical record, of a total sample of 3 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility for respite care from home on 5/23/24, 6/07/24, 7/08/24, 8/23/24, and 9/16/24. The resident discharged home on [DATE], and most recently re-admitted on [DATE]. The resident's diagnoses included: cerebral arteriosclerosis, encounter for palliative care, holiday relief care, Alzheimer's Disease, vascular dementia with behavioral disturbance, gastrostomy (feeding tube), type 2 diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, and insomnia. The most recent comprehensive Minimum Data Set admission assessment with assessment reference date 10/01/24 noted resident #1 was unable to complete the Brief Interview for Mental Status and assessed by staff with severely impaired cognitive…
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 · E2024-02-17 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident was assessed to be clinically appropriate to self-administer medication of a total sample of 45 residents, (#18). Findings: Resident #18, a [AGE] year-old female was admitted to the facility on [DATE], with diagnoses that included mechanical complication of internal fixation device of left femur, asthma, atrial fibrillation, and major depressive disorder. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 1/10/24, revealed the resident's cognition was intact, with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. On 2/12/24 at 11:48 AM, resident #18 was lying in bed, awake, alert, and oriented. Observation showed a handheld inhaler of Albuterol on the resident's tray table. She stated she administered it herself approximately every eight hours. On 2/12/24 at 4:45 PM, resident #18 was sitting up in her bed, working on a cross word puzzle. The Albuterol inhaler…
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 · E2024-02-17 · 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
Based on observation, and interview, the facility failed to provide a homelike environment for all residents who ate their meals in the main dining room, by serving the resident's meals on serving trays at the table in an institutional manner. Findings: On 2/13/24 at 12:30 PM, during meal observation in the main dining room,13 residents were observed seated at the tables in the dining room. Each resident was noted to have a serving tray on the table in front of them which contained the lunch meal. The plates, cups, bowls and eating ware remained on the tray and were not removed from the trays at the table. On 2/13/24 at 4:46 PM, during meal observation, 12 residents were observed seated in the main dining room. Each resident had a serving tray in front of them with their meal, dinnerware and eating utensils on the tray. On 2/13/24 at 4:50 PM, Certified Nursing Assistant (CNA) P was in the dining room. She acknowledged she was the only staff person in the dining room and had served meals to all 12 residents. CNA P stated the meals were always served on trays in the dining room. 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.
- Potential for harm · E2024-02-17 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an on-going individualized program of activities for 2 of 2 residents reviewed for activities of a total sample of 45 residents, (#2, #79). Findings: Record review revealed resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes type II, Chronic Obstructive Pulmonary Disease (COPD), heart disease, psychosis, dementia, blindness of her right and left eye, anxiety disorder, and cognitive communication deficit The annual Minimum Data Set (MDS) assessment, with assessment reference date of 2/24/23 revealed resident #2 had a Brief Interview of Mental Status score of 7 which indicated the resident had severe cognitive impairment. Section F- Preferences for customary routine and activities revealed code 1 was documented, indicating it was very important to the resident for the following activities: listen to music she liked, be around animals such as pets, do things with groups 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 before2024-02-17 · tag F0867 — failed to act on quality-improvement findings — patternSet 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
Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented effective Performance Improvement Plans (PIPs) to correct and monitor identified deficiencies, and ensure sustained improvements. Findings: In a joint interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 2/17/24 at 3:51 PM, the NHA stated the facility's QAPI committee implemented PIPs to address regulatory noncompliance identified during surveys, and as needed. The DON provided a document dated 6/09/23 that she identified as a PIP for falls. She explained the Regional Director of Operations had re-implemented the plan on 2/16/24. She noted they intended to identify opportunities for improvement related to fall occurrences that included investigations and identification of the root causes and stated, so we can put a true intervention in place. The NHA said regulatory compliance was discussed when any entity visited the facility whether it was a State Agency, Department, or the Ombudsman. He stated there was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-17 · 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 observation and interview, the facility failed to ensure residents' dignity was maintained, by failing to knock on doors prior to entry during dining observation on 1 of 2 wings, (East Wing). Findings: On 2/12/24 at 12:08 PM, during dining observation on the East Wing, Certified Nursing Assistant (CNA) D was observed serving meal trays. CNA D entered rooms 101, 104, 105, 106, and room [ROOM NUMBER], and did not knock on the doors, or announced herself prior to entry. On 2/12/24 at 12:15 PM, CNA D donned appropriate Personal Protective Equipment (PPE), for Transmission Based Precaution (TBP) to deliver meal trays to residents in room [ROOM NUMBER]. The CNA did not knock on the door prior to entry and used her foot to push the door open. On 2/12/24 at 12:33 PM, CNA D acknowledged she did not knock on the residents' doors prior to entering rooms to serve meal trays. The CNA stated that normally she did not knock on the doors, but just went in and dropped off the trays. On 2/17/24 at 9:08 AM, resident #83…
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 21 citations
- Potential for harm · Dcited before2024-02-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to thoroughly investigate an incident involving neglect and failed to report the results of the investigation to the State Survey Agency related to an avoidable fall with major injury for 1 of 6 residents sampled for falls, of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, muscle weakness. On 2/09/24, a diagnosis fracture of unspecified part of left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate hearing, had clear speech, was understood, and understands, and had adequate vision.…
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 before2024-02-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted for a fall with fracture for 1 of 6 residents reviewed for falls of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, the diagnosis, fracture of unspecified part of left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate hearing, clear speech, was understood, and understands, and had adequate vision. The assessment indicated the resident was independent for eating, oral hygiene, and personal hygiene,…
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 before2024-02-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected health conditions regarding bladder and bowel for 1 of 1 resident reviewed for urinary catheter, of a total sample of 45 residents, (#20). Findings: Record review revealed resident #20 was a 52- year-old-male admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included hydronephrosis with ureteral stricture, spinal muscular atrophies, paranoid schizophrenia, malignant neoplasm of prostate, paraplegia, and anoxic brain damage. Review of the resident's Medical Certification For Medicaid Long-term Care Services And Patient Transfer Form (3008) dated 3/01/22 revealed the resident had a colostomy, and a right Urostomy/nephrostomy. A colostomy is surgery to create an opening called a stoma. The opening creates a passage from the large intestines to the outside of your body . so that solid stool and gas can leave the body through the stoma instead 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 · D2024-02-17 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a Baseline Care Plan timely for 2 of 2 residents of a total sample of 45 residents, (#25, #82). Findings: 1. Review of the medical record revealed resident #25, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Alzheimer's Disease, malnutrition, diabetes, failure to thrive, and need for assistance with personal care. The Baseline Care Plan scanned to the Electronic Health Record (EHR) noted the nurse signed the plan of care was developed on 10/15/23. The document did not indicate any notations or signatures that indicated the resident or resident's representative was included. On 2/16/24 at 9:30 AM, the MDS Coordinator explained development of the Baseline Care Plan was included in the initial admissions process that staff nurses on the units completed. He said immediate treatment plans were important and the resident or resident representative needed to be involved as, it…
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 · D2024-02-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview, and record review, the facility failed to accurately assess a resident's vision and failed to initiate a comprehensive care plan for impaired vision for 1 of 2 residents reviewed for vision/hearing of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, diabetes, and fracture of left clavicle. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate vision and was independent with eating. On 2/13/24 at 8:40 AM, Certified Nursing Assistant, (CNA) Q explained to resident #197 where the food was situated on her plate. The CNA stated the resident did not see very well so we always make sure she knows where the food and drinks are situated on her…
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 · D2024-02-17 · 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 interview and record review, the facility failed to ensure 2 residents/representatives were provided the opportunity to participate in their care plan reviews, (#33, #58); and failed to ensure 2 residents/representatives were invited and participated in the development of care plans, (#80, #83), of a total sample of 45 residents. Findings: 1. Review of the medical record revealed resident #33, a [AGE] year old female was admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/07/23. Her diagnoses included thoracic vertebra (mid-spine) fractures, heart failure, pulmonary (lung) hypertension, atrial fibrillation (heart rhythm dysfunction), Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, malnutrition and, type 2 diabetes mellitus with kidney disease. The most recent Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) of 2/01/24 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated…
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 before2024-02-17 · 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 observation, interview, and record review, the facility failed to provide mouth care for 1 of 5 residents observed for Activities of Daily Living (ADL) care of a total sample of 45 residents, (#72). Findings: Resident #72 was admitted to the facility on [DATE] with diagnoses to include stroke, difficulty swallowing, aphasia, and need for assistance with personal care. The resident's 5-day Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 1/13/24 revealed the resident's cognition was severely impaired. The assessment noted his speech was unclear and he required maximum assistance for oral hygiene. The assessment noted the resident did not have any behaviors. On 2/13/24 at 3:14 PM, the resident was observed lying in bed with his eyes closed. He had his mouth open and his tongue and teeth were coated with a thick white substance. On 2/14/24 at 10:43 AM, the resident was observed lying in bed awake looking at the television. His tongue and teeth were coated with a thick white…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-17 · 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 observation, interview, and record review, the facility failed to ensure enteral feeding was infused as prescribed by the physician for 1 of 2 residents reviewed for tube feeding, of a total sample of 45 residents, (#83). Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. (Retrieved from https//www.healthline.com 2/27/24). Findings: Resident #83, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes type II, asthma, gastrostomy, heart failure, hyperlipidemia, hypertension, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview for Mental status (BIMS) of 15 out of 15. The assessment revealed the resident had a feeding tube, and received a mechanically altered, and therapeutic diet. The resident's physician's order dated 9/16/23 noted Glucerna 1.5 continuous at 65 milliliters (ml) per…
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 · D2024-02-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Oxygen (O2) therapy was administered at the correct flow rate as per the physician's order and care plan intervention for 1 of 1 resident, reviewed for O2 therapy, of a total sample of 45 residents, (#2). Findings: Review of the clinical record revealed resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes type II, Chronic Obstructive Pulmonary Disease (COPD), heart disease, psychosis, dementia, blindness of her right and left eye, anxiety disorder, and cognitive communication deficit. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 3 out of 15. The assessment revealed the resident was dependent on staff assistance for eating, toileting hygiene, and personal hygiene, and indicated the resident received O2 therapy. The resident's physician…
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 · D2024-02-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to follow physician orders for 1 of 5 residents reviewed for unnecessary medications of a total sample of 45 residents, (#57). Resident #57 was admitted to the facility on [DATE] with diagnoses to include diabetes, hypertension, dementia, and depression. Review of the physician orders indicated the resident received Glimepiride, Januvia, Metformin, and Novolog insulin by sliding scale for diabetes. Review of the Medication Regimen Review for January 2024 indicated a recommendation to change Glimepiride 4 milligrams (mg) (long-acting agent) to a short acting agent ( Glipizide). The review noted the physician agreed with the recommendation and on 1/05/24 ordered Glipizide 2 mg. daily. Review of the order in resident #57's medical record read, Glimepiride 2 mg and not Glipizide 2 mg which was ordered. On 2/17/24 at 2:58 PM, the Director of Nursing (DON) stated her expectation was to have the pharmacy recommendations completed within 72 hours. She stated her…
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 before2023-11-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin to the relevant State Regulatory Agency within the specified timeframe for 1 of 5 residents of a total sample of 5 residents, (#1). Findings: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy, dementia, diabetes type II, anxiety disorder, mood (affective) disorder, and nondisplaced fracture of the base of neck of the right femur, and chronic pain. Review of the incident log for the period March 2023 to current revealed an entry on 11/12/23, indicating the resident had bruises. Review of the eInteract change in condition form dated 11/12/23, revealed the resident had uncontrolled pain, bruise to her right eye and forehead, right shoulder pain, and indicated the physician was notified on 11/12/23 at 8:40 AM, and recommended x-rays, three views. The resident's physician order dated 11/12/23, was for x-ray, two views 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 · Dcited before2023-11-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate a potential fall for 1 dependent resident of a total sample of 5 residents, (#19). Findings: Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes type II, pain in leg, left artificial hip joint, left knee contracture, bipolar disorder, dementia, and on 11/01/23 displaced fracture of lower epiphysis (separation) of left femur was added. Review of the facility's Incident Log showed entry for resident #19 of an unwitnessed fall on 10/26/23 at 10:55PM. Review of the resident's hospital's history and physical dated 10/27/23 revealed the resident presented to the Emergency Department for a ground-level fall, and read, Patient found to have a left leg deformity. Unknown mechanism of fall because of dementia .Ortho following plans for OR (operating room) for fixation today. Documentation revealed the resident's principal problem was a, closed displaced…
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 · D2023-11-15 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the hospital discharge instructions for a surgical wound, and a wound management system were transcribed to the resident's electronic medical record, to ensure appropriate monitoring by nurses for 1 resident, of a total sample of 5 residents, (#19). Findings: Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes type II, pain in leg, left artificial hip joint, left knee contracture, bipolar disorder, dementia, and on 11/01/23 displaced fracture of lower epiphysis (separation) of left femur was added. Review of the hospital Discharge summary dated [DATE], revealed the resident's admission and discharged diagnosis was a closed displaced fracture of the distal epiphysis of the left femur. Documentation read, brought by EMS (Emergency Medical Services) . d/t (due to) left leg deformity after a fall. He was found to have left Vancouver C distal femur fracture 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 · D2023-11-15 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
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 physician orders for stat x-rays were obtained in a timely manner for 1 resident of a total sample of 5 residents, (#1). Findings: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy, dementia, diabetes type II, anxiety disorder, mood (affective) disorder, nondisplaced fracture of the base of neck of the right femur, and chronic pain. Review of the resident's eInteract change in condition form dated 11/12/23, revealed the resident experienced uncontrolled pain, had bruises to her right eye and right forehead, and pain to her right shoulder. The document indicated the physician was notified on 11/12/23 at 8:40 AM, and recommended x-rays 3 views. Review of the resident's physician orders, revealed order dated 11/12/23 for two view x-rays of the right shoulder and facial bone. A progress note documented on 11/12/23 at 10:06 PM by the weekend…
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 before2022-04-13 · 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 observation, interview and record review, the facility failed to maintain resident's dignity during dining for 4 of 15 residents assessed for dining of a total sample of 43 residents, (#37, #27, #52 & #54). Findings: 1. Resident # 37 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, dementia, and type 2 diabetes. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated resident #37 had severe cognitive impairment and was totally dependent on staff for eating. Review of the resident kardex used by Certified Nursing Assistants (CNA) to guide the care of the resident, indicated the resident was totally dependent on one staff for eating. Review of the medical record revealed an Activity of Daily Living (ADL) care plan dated, 12/08/21 which indicated the resident required total assistance of one person for feeding. On 04/10/22 at 1:02 PM, CNA H was observed standing at the left side of resident #37's bed. The CNA was watching television that was on the wall…
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 before2022-04-13 · 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 observation, interview, and record review, the facility failed to provide personal hygiene care for a resident dependent on staff for activities of daily living (ADLs) for 1 of 4 residents reviewed for ADL care in a total sample of 43 residents, (#93). Findings: Resident #93 was admitted to the facility on [DATE]. Her diagnoses included dementia, cerebral vascular accident (CVA), dysphasia, hemiparesis of the left dominant side, and impaired visual function. She started hospice services on 11/2/21 post Coronavirus Disease 2019 diagnosis. Resident #93's quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 3/17/22 noted the resident had a Brief Interview for Mental Status (BIMS) Score of 3 out of 15 which indicated severe cognitive deficit. Review of Section G related to Functional Status revealed the resident required supervision of one staff person to eat, and was totally dependent on one staff person for personal hygiene and bath care needs. Resident #93's ADL 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.
- Potential for harm · D2022-04-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and provide wound care services for 1 of 1 resident reviewed with a reoccurring left heel wound in a total sample of 43 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses that included history of sacral pressure ulcers and a reoccurring left heel wound. She had multiple co-morbidities that included heart failure, obesity, bilateral artificial knee joints, rheumatoid arthritis, fibromyalgia, limited mobility, muscle spasms, seizures, and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 2/22/22 showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The assessment indicated she did not have any wounds at that time. On 4/10/22 at 12:17 PM, resident #53 was observed sitting up in bed. She had a low-loss air mattress and a large positioning bolster on the 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 · D2022-04-13 · 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 observation, interview, and record review, the facility failed to provide appropriate suprapubic catheter care and services to reduce the risk of potential bladder infections for 1 of 2 residents (#53) reviewed in a total of 6 residents with indwelling or external urinary catheters. Findings: Resident #53 was admitted to the facility on [DATE]. Her diagnoses included heart failure, obesity, obstructive and reflux uropathy, and use of a suprapubic urinary catheter. On 4/10/22 at 12:17 PM, resident #53 in bed and her suprapubic urinary catheter bag was secured to the bedframe. The catheter tubing was noted with cloudy, amber urine with multiple thick clumps and strands of milky colored sediment. The resident indicated the Certified Nursing Assistants (CNAs) emptied her catheter bag every day but the nurses had not flushed the catheter in a while. A review of resident #53's most recent Quarterly Minimum Data Set Assessment with an assessment reference date (ARD) of 2/22/22 noted she was cognitively intact…
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 · D2022-04-13 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 palatable meals for 1 of 4 residents reviewed for food of a total sample of 43 residents, (#51). Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes mellitus, hypertension, hyperlipidemia, and depression. Review of the physician orders reflected the resident's diet was consistent carbohydrates, no added salt and mechanical soft consistency. The Minimum Data Set (MDS) 5-day Medicare assessment, dated, 3/22/21 revealed the resident was alert and oriented, had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact, and he required supervision with his meals. On 4/10/22 at 11:48 AM, resident #51 complained his food was usually cold by the time it was delivered to his room. On 4/11/22 at 9:49 AM, the resident stated he was not able to eat his breakfast that morning as his toast was cold. On 4/11/22 at 12:37 PM, resident #51's lunch tray…
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 · D2022-04-13 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and honor food preferences for 1 of 4 residents reviewed for food of a total sample of 43 residents, (#51). Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes mellitus, hypertension, hyperlipidemia, and depression. Review of the physician orders reflected the resident's diet was consistent carbohydrates, no added salt and mechanical soft consistency. The Minimum Data Set (MDS) 5-day assessment, dated, 3/22/21 revealed the resident had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact, and noted he required supervision with eating. On 04/10/22 at 11:48 AM, resident #51 stated he rarely received a food tray that reflected the items listed on his meal ticket. He said, They always lie. I never get what's written there. On 04/10/22 at 12:58 PM, the resident's lunch tray revealed apple juice, green peas, carrots, mashed potatoes, apple…
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.
- No harm found · C2022-04-13 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to post their licensed and unlicensed nursing staff data on a daily basis and/or in a timely manner for three consecutive days (4/8/22, 4/9/22, and 4/10/22). Findings: On Sunday 4/10/22 at 10:05 AM, the nursing staff data form was observed posted in the front lobby by the receptionist's window. The form was dated three days earlier, 4/7/22. The nursing staff form did not include the resident census. On 4/10/22 at 10:10 AM, the weekend Receptionist F explained she was responsible to complete and post the daily nursing staff data forms on Saturdays and Sundays. She said that from Monday through Friday, the Staffing Coordinator completed and posted the form. She reported her shift started at 8 AM and that she had been busy and had not yet completed the 4/10/22 nursing staff form. She acknowledged nursing staff started their day shift at 7 AM, three hours earlier. The Receptionist conveyed she was unsure why the daily nursing staff data forms had not been posted on Friday 4/8/22 and Saturday 4/9/22. On 4/13/22 at…
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
$73,968 in federal fines across 1 penalty.
- $73,968 — penalty dated 2024-02-17
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 SIMCHA HYMAN & NAFTALI ZANZIPER — 79 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 | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; 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 / manager | Type | Role | Since |
|---|---|---|---|
| FULTON, NICOLE | Individual | W-2 MANAGING EMPLOYEE | since 04/01/2020 |
| GORELICK, BATYA | Individual | CORPORATE OFFICER | since 04/01/2020 |
| ORCHID COVE HEALTH GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 02/06/2020 |
| TERENTEV, ALEX | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2020 |
The source lists no ownership percentage for any party here — 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.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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
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 105332. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-10, 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.