Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 15, 2025
Visit Reason
The inspection was conducted based on complaints regarding language barriers between staff and residents, and issues with facility environment including sewage odor and malfunctioning toilets.
Complaint Details
Numerous complaints were received regarding language barriers between staff and residents since October 2025. Complaints also included ongoing sewage odor and frequent toilet clogs in resident bathrooms. Staff and residents reported difficulties communicating due to language differences, and the facility acknowledged ongoing plumbing and odor issues for several months.
Findings
The facility failed to ensure residents were treated with respect and dignity due to language barriers between staff and residents, impacting communication and resident preferences. Additionally, the facility failed to maintain a safe, clean, and homelike environment due to ongoing sewage odors and multiple clogged or malfunctioning toilets in resident bathrooms.
Deficiencies (2)
Failure to ensure residents were treated with respect and dignity due to staff language barriers impacting communication.
Failure to maintain a safe, clean, comfortable, and homelike environment including unresolved sewage odor and multiple clogged toilets in resident bathrooms.
Report Facts
Residents reviewed: 16
Residents affected: 4
Resident rooms observed: 68
Unit zones affected: 6
Toilets clogged or malfunctioning: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding complaints about CNAs who did not speak English |
| Social Services Director | Reported numerous complaints about language barriers and grievance process | |
| Director of Nursing | Provided information on language line, bilingual staff, and training regarding language barriers | |
| Staff I | Receptionist | Confirmed sewage odor and complaints from visitors and residents |
| Housekeeping Director | Observed attempting to unclog toilets and confirmed ongoing sewage odor | |
| Maintenance Director | Confirmed ongoing toilet flushing issues and sewage odor, described maintenance procedures | |
| Nursing Home Administrator | Confirmed ongoing sewage odor and toilet issues, and complaint follow-up process | |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed sewage odor and toilet clog complaints |
| Staff C | Certified Nursing Assistant (CNA) | Confirmed sewage odor and toilet clog complaints |
| Staff D | Certified Nursing Assistant (CNA) | Confirmed sewage odor and toilet clog complaints |
| Dietary Manager | Confirmed sewage odor complaints | |
| Staff F | Social Service | Confirmed sewage odor complaints |
| Business Office Manager | Confirmed sewage odor complaints |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal and state regulations related to resident care, treatment, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop a comprehensive care plan addressing PTSD for a resident, inadequate treatment and monitoring of skin conditions for two residents, failure to provide ordered enteral feeding for a resident, and deficiencies in food service operations including dishwashing machine temperature issues, walk-in freezer icing, lack of refrigerator thermometer, and lack of soap at a handwashing sink.
Deficiencies (7)
Failed to develop care plan problem areas with goals and interventions related to Post Traumatic Stress Disorder (PTSD) for Resident #151.
Failed to ensure two residents received treatment and care in accordance with professional standards related to timely response to skin condition changes and monitoring/providing care to occlusive dressing.
Failed to prevent enteral feeding complications related to not providing the ordered nutrition for Resident #28.
Failed to ensure dishwashing machine operated at required low temperature wash and rinse specifications.
Walk-in freezer had icing and ice sheeting buildup on floors, walls, shelving, and packaged food items.
Walk-in refrigerator lacked an internal thermometer and temperature logs were not available.
Hand washing sink lacked soap for proper hand hygiene.
Report Facts
Feeding pump rate: 70
Feeding pump rate observed: 65
Dish machine wash temperature: 103
Dish machine rinse temperature: 119
Dish machine wash temperature second test: 115
Dish machine rinse temperature second test: 118
Dish machine sanitizer PPM: 50
Walk-in freezer ice sheet size: 3
Walk-in freezer ice thickness: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Minimum Data Set (MDS)/Care Plan Coordinator | Interviewed regarding Resident #151 PTSD care plan deficiency |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #151 PTSD care plan and Resident #26 wound care |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #26 complaints of pain |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #26 pain complaints and care |
| Staff G | Licensed Practical Nurse (LPN)/Unit Manager | Interviewed regarding Resident #26 wound care and treatment orders |
| Staff K | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #67 IV dressing and Resident #28 enteral feeding |
| Staff L | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #67 IV dressing |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding kitchen sanitation and dishwashing machine issues |
| Staff A | Dietary Aide | Observed operating dishwashing machine |
| Staff B | Dietary Aide | Observed operating dishwashing machine |
| Maintenance Director | Maintenance Director | Interviewed regarding walk-in freezer ice buildup |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 16, 2021
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident rights, notification procedures, medication management, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to document advance directives for a resident, failure to notify the State Long-Term Care Ombudsman of resident transfers, failure to provide written notice of bed hold policies upon resident transfers, and failure to act upon consultant pharmacist recommendations regarding medication discontinuation.
Deficiencies (4)
Failed to ensure the advance directive for a resident was identified in the medical record.
Failed to notify the Office of the State Long-Term Care Ombudsman of a facility initiated transfer for one resident.
Failed to provide written notice of bed hold upon a facility initiated transfer for two residents.
Did not ensure the consultant pharmacist's recommendations were acted upon for one resident regarding unnecessary medications.
Report Facts
Residents sampled: 35
Residents sampled: 2
Medication dosage: 12.5
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported code status should be listed on top of electronic health record screen |
| Nurse Liaison | Stated code status should be at top of electronic medical record and book on unit for Do Not Resuscitate status | |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding notification failures and bed hold notices |
| Social Services Director (SSD) | Social Services Director | Interviewed regarding failure to notify LTC Ombudsman and plans to improve notification |
| Admissions Nurse Liaison | Interviewed about medication recommendation communication process | |
| Regional Nurse | Interviewed about pharmacist recommendations and medication administration | |
| Consultant Pharmacist | Interviewed about medication review and recommendation process | |
| Director of Nursing (DON) | Director of Nursing | Responsible for dispersing pharmacist recommendations to unit managers and doctors |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Receives pharmacist recommendations |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 10, 2020
Visit Reason
The inspection was conducted due to complaints regarding inadequate fall interventions, medication errors, infection control issues, and catheter care at Heritage Park Health Center by Harborview.
Complaint Details
The investigation was complaint-driven, focusing on fall prevention failures, medication errors, infection control breaches, and catheter care deficiencies.
Findings
The facility failed to ensure adequate fall prevention interventions for a high-risk resident, failed to provide timely and accurate medication administration for another resident, did not implement proper infection prevention and control measures including contact precautions for a resident with MRSA, and did not maintain catheter bags off the floor for multiple residents. Additionally, medication administration practices were unsanitary for a resident with a gastrostomy tube.
Deficiencies (5)
Failed to ensure adequate fall interventions for Resident #226 who had multiple falls shortly after admission.
Failed to provide admission medications related to pain, anxiety, and antibiotics for Resident #333 after hospital transfer.
Did not implement appropriate infection control measures including contact precautions for Resident #184 with MRSA.
Failed to maintain catheter bags off the floor for Residents #54, #58, and #64.
Medication administration for Resident #45 was unsanitary, including failure to clean medication binder and improper hand hygiene.
Report Facts
Fall events: 2
Medication administration failures: 6
Catheter care observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Registered Nurse (RN) | RN working as sitter for Resident #226 during observation. |
| Staff M | Rehab Director | Interviewed regarding side rail evaluations and fall risk for Resident #226. |
| Staff K | Social Services Director (SSD) | Interviewed about Resident #226's confusion and 1:1 care recommendation. |
| Staff L | Weekend Nursing Supervisor | Directed frequent checks and 1:1 supervision for Resident #226. |
| DON | Director of Nursing | Investigated falls of Resident #226 and acknowledged incomplete investigations; also interviewed regarding medication errors and infection control. |
| Staff H | Licensed Practical Nurse (LPN) | Interviewed about medication availability for Resident #333. |
| Staff A | Registered Nurse (RN) | Observed administering medications unsanitarily to Resident #45. |
| Staff I | Certified Nursing Assistant (CNA) | Interviewed about catheter care and bag placement. |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed about catheter care and observed catheter bag dragging. |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed about catheter care and bag placement. |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed about catheter dignity bag use. |
| Staff O | Registered Nurse (RN) | Infection control nurse interviewed about MRSA precautions and facility policies. |
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