Inspection Report Summary
The most recent inspection on September 19, 2024, found no deficiencies. Earlier inspections showed a mix of deficiency findings, including issues related primarily to staffing standards, medication management, and staff records. Complaint investigations did not result in substantiated findings, and no fines or enforcement actions were listed in the available reports. Prior reports included some Class 3 and Class 4 deficiencies but no license suspensions or fines were noted. The overall trend suggests improvement, with the latest inspection showing no cited deficiencies after past issues were addressed.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
No deficiencies noted during this inspection.
Findings
No deficiencies noted during this inspection.
Inspection Report
Standard
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2024 with deficiency history and inspection statuses.
Findings
Across the inspections from 2012 to 2024, the facility had a mix of deficiency findings including cited, corrected, and no deficiencies. The most recent inspections in 2024 showed cited deficiencies, corrected deficiencies, and no deficiencies.
Report Facts
Inspections on page: 43
Inspection Report
Routine
Deficiencies: 1
Date: May 9, 2024
Visit Reason
Deficiency related to staffing standards with Class 3 severity.
Findings
Deficiency related to staffing standards with Class 3 severity.
Deficiencies (1)
Tag A0078 — STAFFING STANDARDS - STAFF
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure proper PASRR screening for residents with mental disorders or intellectual disabilities and failure to provide timely nail care and grooming services as per residents' care plans.
Complaint Details
The complaint investigation revealed that Resident #29 was not re-evaluated with a Level 2 PASRR despite indications from a Level 1 PASRR that such evaluation was required. Additionally, Resident #25 did not receive timely nail care as required by their care plan, despite being on antiplatelet therapy which increases risk.
Findings
The facility failed to ensure that a resident with a serious mental illness received the required Level 2 PASRR evaluation and failed to provide timely nail care and grooming to another resident as outlined in their care plans. Observations, interviews, and record reviews confirmed these deficiencies affecting a few residents.
Deficiencies (2)
Failure to ensure a resident with a serious mental illness received a required Level 2 PASRR evaluation.
Failure to provide timely nail care and grooming services per the resident's comprehensive care plan.
Report Facts
Residents in sample: 20
PASRR Level 1 date: Jun 10, 2020
MDS assessment date: Jan 21, 2024
Medication dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director B | Social Services Director | Interviewed regarding PASRR screening process and referral responsibilities |
| Registered Nurse A | Registered Nurse | Interviewed regarding nail care responsibilities and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
The inspection was conducted based on complaints alleging failure to treat residents with dignity and respect, failure to provide medication as ordered, failure to administer tube feedings as ordered, failure to provide oxygen at prescribed flow rates, and medication errors.
Complaint Details
The complaint investigation was substantiated with findings of disrespectful treatment of residents, medication administration errors, failure to administer tube feedings as ordered, incorrect oxygen flow rates, and a medication error rate of 13.33%.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to administer medications and tube feedings as ordered, failure to provide oxygen at the prescribed flow rate, and a medication error rate exceeding 5%. Several residents experienced inadequate care related to incontinence, medication administration, enteral feeding, and respiratory therapy.
Deficiencies (5)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, including incidents where residents were treated disrespectfully by staff.
Failure to provide treatment and care according to orders, resident’s preferences and goals, specifically failure to administer lithium medication as ordered for Resident #74.
Failure to administer tube feedings as ordered by the physician for Resident #44.
Failure to provide oxygen at the prescribed flow rate for Resident #31, with oxygen flow set higher than ordered.
Medication error rate exceeded 5%, with four errors out of 30 opportunities involving multiple residents, including insulin administration errors and incomplete medication administration via feeding tube.
Report Facts
Medication error rate: 13.33
Medication errors: 4
Residents sampled: 30
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication error finding and enteral feeding deficiency |
| LPN D | Licensed Practical Nurse | Interviewed regarding medication administration for Resident #74 |
| RN B | Registered Nurse | Named in medication error finding related to insulin administration |
| LPN C | Licensed Practical Nurse | Named in medication error finding related to incomplete medication administration via feeding tube |
| RN F | Registered Nurse | Interviewed regarding oxygen flow rate for Resident #31 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding multiple deficiencies including dignity, medication administration, oxygen therapy, and medication errors |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and medication supply issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 2, 2020
Visit Reason
Two Class 3 deficiencies related to medication self-administration and staff records.
Findings
Two Class 3 deficiencies related to medication self-administration and staff records.
Deficiencies (2)
Tag A0050 — MEDICATION - SELF ADMINISTERED MEDICATIONS
Tag A0161 — RECORDS - STAFF
Inspection Report
Deficiencies: 1
Date: Oct 4, 2020
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews to assess the facility's compliance with residents' rights to a dignified existence, self-determination, communication, and privacy during personal care.
Findings
The facility failed to ensure staff knocked and announced themselves prior to entering resident rooms and failed to provide privacy to residents during personal care for two residents (#609 and #610). Observations included uncovered residents, open doors, illuminated call lights, and staff entering rooms without knocking or identifying themselves. Interviews with staff confirmed expectations for privacy and dignity were not consistently met.
Deficiencies (1)
Failure to ensure staff knocked and announced themselves prior to entering resident rooms and failure to provide privacy during personal care for two residents.
Report Facts
Residents sampled: 34
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee I | Certified Nursing Assistant (CNA) | Observed entering Resident #609's room without knocking or introducing herself |
| Employee J | Licensed Practical Nurse (LPN) | Entered Resident #609's room without knocking or identifying herself |
| Employee E | Licensed Practical Nurse (LPN) | Observed providing care to Resident #610 with door open and privacy curtain not pulled |
| Employee H | Certified Nursing Assistant (CNA) | Interviewed regarding privacy practices |
| Employee G | Certified Nursing Assistant (CNA) | Interviewed regarding privacy practices |
| Employee D | LPN/Clinical Services Manager | Interviewed regarding staff responsibilities for call lights and resident privacy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2019
Visit Reason
One Class 4 deficiency related to background screening and prohibited offenses.
Findings
One Class 4 deficiency related to background screening and prohibited offenses.
Deficiencies (1)
Tag CZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2018
Visit Reason
Two Class 3 deficiencies related to staffing standards and staff records.
Findings
Two Class 3 deficiencies related to staffing standards and staff records.
Deficiencies (2)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0161 — RECORDS - STAFF
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 19, 2017
Visit Reason
One Class 3 deficiency related to medication labeling and orders.
Findings
One Class 3 deficiency related to medication labeling and orders.
Deficiencies (1)
Tag A0056 — MEDICATION - LABELING AND ORDERS
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 10, 2017
Visit Reason
Four Class 3 deficiencies related to admissions health assessment, resident care rights, and medication assistance.
Findings
Four Class 3 deficiencies related to admissions health assessment, resident care rights, and medication assistance.
Deficiencies (3)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Inspection Report
Routine
Deficiencies: 1
Date: May 10, 2016
Visit Reason
One Class 3 deficiency related to medication assistance with self-administration.
Findings
One Class 3 deficiency related to medication assistance with self-administration.
Deficiencies (1)
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Inspection Report
Routine
Deficiencies: 4
Date: Apr 23, 2014
Visit Reason
Four deficiencies: three Class 3 related to staffing, training, and DNRO orders; one Class 4 related to background screening.
Findings
Four deficiencies: three Class 3 related to staffing, training, and DNRO orders; one Class 4 related to background screening.
Deficiencies (4)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag AZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES
Inspection Report
Monitor
Deficiencies: 2
Date: Sep 11, 2013
Visit Reason
Two Class 3 deficiencies related to medication administration and medication records.
Findings
Two Class 3 deficiencies related to medication administration and medication records.
Deficiencies (2)
Tag A0053 — MEDICATION - ADMINISTRATION
Tag A0054 — MEDICATION - RECORDS
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