Inspection Report Summary
The most recent inspection on April 15, 2025, cited deficiencies related to staffing levels and resident records. Earlier inspections showed a pattern of similar issues, including staffing, resident care, medication assistance, training, and background screening, with some deficiencies corrected over time. Inspectors frequently noted staffing standards and resident recordkeeping as areas needing attention. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports, and no complaint investigations were reported. The inspection history indicates ongoing challenges with staffing and documentation, with no clear trend of improvement or worsening in recent years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
Deficiencies related to staffing levels and resident records.
Findings
Deficiencies related to staffing levels and resident records.
Deficiencies (2)
Tag A0079 — STAFFING STANDARDS - LEVELS
Tag A0162 — RECORDS - RESIDENT
Inspection Report
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
Across all inspections, the facility had multiple inspections with mostly no deficiencies, but several inspections cited deficiencies and some later corrected them. The most recent inspection in 2025 cited deficiencies.
Report Facts
Inspections on page: 19
Inspection Report
Routine
Deficiencies: 5
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, respiratory care, and food service sanitation at Indigo Manor nursing home.
Findings
The facility was found deficient in several areas including failure to provide adequate toenail care for a resident dependent on ADLs, inadequate supervision to prevent accidents related to smoking materials, improper oxygen flow rate management for a resident, medication errors exceeding 5%, and failure to maintain proper sanitation and food handling practices in the kitchen.
Deficiencies (5)
Failure to provide toenail care for a resident dependent on activities of daily living, resulting in toenails extending approximately one half inch beyond the nail bed and jagged.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents related to a resident possessing smoking materials.
Failure to provide safe and appropriate respiratory care by not ensuring a resident received oxygen at the ordered flow rate.
Medication error rate exceeded 5%, with two medication errors out of 25 opportunities involving two residents.
Failure to follow proper sanitation and food handling practices including not logging proper temperatures for dish machine and chemical sanitization, and presence of food buildup on kitchen mixer.
Report Facts
Residents reviewed for ADLs: 4
Total survey sample residents: 41
Medication error rate: 8
Medication error count: 2
Medication opportunities for error: 25
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 4
Dish machine wash temperature: 140
Dish machine rinse temperature: 145
Chemical sanitization ppm: 190
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant B | CNA | Reported on care practices and observations related to Resident #33's toenail care |
| Licensed Practical Nurse C | LPN | Provided information on toenail care policies and observations for Resident #33 |
| Assistant Director of Social Services | Described process for arranging podiatrist visits and confirmed no requests for Resident #33 | |
| Assistant Director of Nursing | ADON | Discussed smoking policy enforcement and resident compliance for Resident #7 |
| Certified Nursing Assistant D | CNA | Smoking attendant responsible for supervising smoke breaks and enforcing smoking policy |
| Registered Nurse L | RN | Observed nearly medicating wrong resident during medication administration |
| Licensed Practical Nurse M | LPN | Observed nearly administering incorrect medication to Resident #113 |
| Dietary Aide F | Dietary Aide | Reported on dish machine use and sanitation practices |
| Dietary Aide H | Dietary Aide | Provided information on dish machine and 3-compartment sink sanitation testing |
| Dietary Aide I | Dietary Aide | Described dish machine rotation and sanitation testing procedures |
| Dietary Aide J | Dietary Aide | Responsible for washing pots and pans and cleaning mixer; reported last training two years ago |
| Certified Dietary Manager | CDM | Confirmed sanitation standards and responsibilities for dish machine and 3-compartment sink |
| Licensed Practical Nurse K | LPN | Verified oxygen flow rate discrepancy for Resident #137 |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident personal funds management and the safety and sanitation of the facility's kitchen area.
Findings
The facility failed to convey resident funds within 30 days upon discharge for two residents and failed to notify one resident when their account balance approached the eligibility limit. Additionally, the kitchen was found to have a leaking ceiling covered by plastic sheets and missing ceiling tiles in the dish room, posing safety and sanitation concerns.
Deficiencies (2)
Failed to convey resident funds within 30 days upon discharge and failed to notify resident when account balance reached $200 less than eligibility limit.
Failed to maintain kitchen in a safe and sanitary manner due to ceiling area covered with plastic sheets dripping liquid and missing ceiling tiles in the dish room.
Report Facts
Credit balance: 510.65
Credit balance: 1247.76
Credit balance: 2213.13
Timeframe for refund issuance: 30
Threshold amount: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident accounts and refund processes |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding kitchen ceiling and sanitation issues |
| Maintenance Director | Maintenance Director | Interviewed regarding kitchen ceiling repairs and maintenance schedule |
| Administrator | Administrator | Interviewed regarding kitchen ceiling condition and repair status |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident safety and prevent elopement of Resident #92, who exited the facility unsupervised and wandered to a busy boulevard.
Complaint Details
The complaint investigation revealed that Resident #92, identified as an elopement risk, was able to leave the facility unsupervised and was found wandering a busy boulevard. The Immediate Jeopardy began on 2023-02-28 at 2:30 p.m. and was identified on 2023-04-12 at 11:30 a.m. The Administrator was notified on 2023-04-13 at 2:30 p.m. and the Immediate Jeopardy was ongoing at survey exit.
Findings
The facility failed to provide adequate supervision and interventions to prevent Resident #92, identified as an elopement risk, from leaving the premises unsupervised. Three nurses failed to place a Wanderguard or provide sufficient supervision, allowing the resident to elope and be found wandering a busy boulevard, risking serious harm or death. The facility's elopement books were incomplete, training was insufficient, and policies were vague.
Deficiencies (2)
Failure to protect residents from neglect by not providing adequate supervision and interventions to prevent elopement of Resident #92.
Failure to provide supervision and implement interventions to maintain resident safety and prevent elopement for Resident #92.
Report Facts
Facility census: 152
Residents at risk for elopement: 9
Staff members: 211
Licensed nurses: 32
Staff trained in elopement response drill: 24
Staff trained in elopement in-service: 3
Residents at risk for elopement after plan correction: 10
Elopement drills: 5
Staff trained in abuse, neglect, exploitation (ANE): 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Completed clinical admission evaluation and nursing progress notes for Resident #92 |
| Licensed Practical Nurse C | Licensed Practical Nurse | Wrote progress note indicating Resident #92 wandering and checking exit doors |
| Licensed Practical Nurse D | Licensed Practical Nurse | Wrote progress note revealing Resident #92 found walking down boulevard |
| Licensed Practical Nurse E | Licensed Practical Nurse | Explained elopement procedures and confirmed Resident #92's information was missing from elopement book |
| Certified Nursing Assistant G | Certified Nursing Assistant | Explained supervision standards and elopement alarm procedures |
| Certified Nursing Assistant I | Certified Nursing Assistant | Found Resident #92 after elopement and returned him to facility |
| Licensed Practical Nurse F | Licensed Practical Nurse | Assigned to second floor south unit, confirmed placement of Wanderguard on Resident #92 |
| Licensed Practical Nurse K | Licensed Practical Nurse | Confirmed Resident #92's information missing from elopement book and stated she did not use the book |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and participated in interviews regarding elopement incident |
| Director of Nursing | Director of Nursing | Participated in interviews, provided education, and acknowledged concerns about elopement incident |
| Receptionist | Front Desk Receptionist | Explained knowledge of residents at risk for elopement and use of elopement risk book |
| Unit Manager S | Unit Manager | Described updated elopement policy, training, and supervision procedures |
| Licensed Practical Nurse T | Licensed Practical Nurse | Received recent training and participated in elopement drills |
| Receptionist J | Receptionist | Confirmed updated elopement risk book and knowledge of residents at risk |
Inspection Report
Routine
Census: 152
Deficiencies: 14
Date: Apr 13, 2023
Visit Reason
Routine inspection of Indigo Manor nursing home to assess compliance with healthcare regulations including resident care, medication administration, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide advanced notice of Medicare service termination to residents, failure to protect resident privacy, inadequate supervision leading to resident elopement, failure to coordinate PASARR assessments, medication errors, improper medication storage, failure to monitor psychotropic medication use, failure to maintain accurate medical records, and lapses in infection control and food safety practices.
Deficiencies (14)
Failed to provide advanced notice to Medicare beneficiaries when skilled nursing services were terminating.
Failed to protect residents' right to personal privacy and confidentiality of medical records; medication carts left unattended with screens displaying resident information.
Failed to provide supervision and interventions to prevent elopement of a resident at risk, resulting in resident leaving the facility unsupervised.
Failed to coordinate with PASARR program for residents with newly diagnosed serious mental illness.
Failed to provide adequate supervision and interventions to prevent accidents and elopement for a resident at risk.
Administered oxygen at a greater flow rate than ordered for a resident receiving respiratory care.
Failed to ensure shared communication between nursing home and dialysis center for a resident receiving hemodialysis.
Failed to provide routine medication (Cinacalcet) to a resident due to communication and supply issues.
Failed to ensure psychotropic medications were monitored appropriately for side effects and efficacy.
Medication error rate exceeded 5% due to errors in medication administration including failure to instruct resident to rinse mouth after inhaler use and administering expired or incorrect medication.
Failed to store all drugs and biologicals in locked compartments; medications found unsecured in resident rooms.
Failed to follow proper food safety and sanitation practices; ice machine and microwave observed with buildup and contamination.
Failed to maintain accurate resident medical records; medication administration records inaccurately documented medication administration.
Failed to ensure hand hygiene compliance during medication preparation and administration.
Report Facts
Facility census: 152
Medication error rate: 11.11
Missed medication doses: 6
Residents at risk for elopement: 9
Residents at risk for elopement: 10
Staff in-service attendance: 3
Staff attendance at elopement drill: 24
Staff attendance at elopement drill: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication administration errors, privacy breach, and elopement supervision failures |
| LPN D | Licensed Practical Nurse | Named in medication administration errors, elopement supervision failures, and communication issues |
| LPN F | Licensed Practical Nurse | Named in oxygen administration error and elopement supervision |
| LPN L | Licensed Practical Nurse | Named in medication administration and communication issues |
| LPN M | Licensed Practical Nurse | Named in medication administration and communication issues |
| LPN K | Licensed Practical Nurse | Named in elopement book maintenance and training |
| CNA G | Certified Nursing Assistant | Named in elopement supervision and training |
| CNA I | Certified Nursing Assistant | Named in resident elopement recovery |
| LPN E | Licensed Practical Nurse | Named in elopement supervision and training |
| LPN P | Licensed Practical Nurse | Named in oxygen administration |
| LPN C | Licensed Practical Nurse | Named in elopement supervision |
| Administrator | Facility Administrator | Named in elopement incident response and training |
| DON | Director of Nursing | Named in elopement incident response and training |
| Dietary Aide Q | Dietary Aide | Named in food safety and sanitation |
| Certified Dietary Manager R | Certified Dietary Manager | Named in food safety and sanitation |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 2, 2022
Visit Reason
Multiple deficiencies involving admissions, medication assistance, staffing, training, and background screening.
Findings
Multiple deficiencies involving admissions, medication assistance, staffing, training, and background screening.
Deficiencies (10)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0162 — RECORDS - RESIDENT
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Tag CZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 9, 2021
Visit Reason
The inspection was conducted based on complaints regarding inadequate catheter care, pain management, medication storage, and food safety practices at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about catheter care, pain management, medication storage, and food safety. Substantiation status is not explicitly stated.
Findings
The facility failed to properly assess and manage residents with indwelling catheters, failed to provide appropriate pain management for a resident, failed to properly store glucose control solutions on medication carts, and failed to monitor and document refrigerator and freezer temperatures in the kitchen.
Deficiencies (4)
Failed to ensure residents with indwelling catheters were assessed for removal as soon as possible, increasing risk of catheter acquired urinary tract infections.
Failed to provide appropriate pain management by not assessing pain properly or providing interventions for pain relief for a resident requiring such services.
Failed to appropriately store Glucose Control Solutions on medication carts, including missing open dates and lack of knowledge about discard timing.
Failed to implement facility policy for monitoring refrigerator and freezer temperatures, with multiple missing temperature logs.
Report Facts
Residents with Foley catheters in sample: 7
Total sample of residents reviewed: 38
Pain rating: 5
Pain rating: 2
Glucose Control Solution discard timeframe: 90
Missing temperature log dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Employee I checked Resident #52's chart and contacted wound care nurse and ADON regarding catheter orders | |
| Licensed Practical Nurse (LPN) and wound care nurse | Employee M confirmed Resident #52's wound status and catheter care | |
| Assistant Director of Nursing (ADON) | Assisted with Resident #52's record review and catheter order clarification | |
| Licensed Practical Nurse (LPN) | Employee H stated pain management procedures and confirmed no pain medication given to Resident #102 | |
| Certified Nursing Assistant (CNA) | Employee G reported on Resident #102's pain communication | |
| Registered Nurse (RN) | Employee A responsible for medication carts, unaware of control solution discard timing | |
| Kitchen Manager | Provided temperature logs and explained missing entries due to staffing shortages |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 27, 2018
Visit Reason
Deficiencies related to resident care elopement standards, staffing, and physical plant safety.
Findings
Deficiencies related to resident care elopement standards, staffing, and physical plant safety.
Deficiencies (3)
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Inspection Report
Routine
Deficiencies: 4
Date: Jan 30, 2017
Visit Reason
Deficiencies involving resident care elopement, medication labeling, staffing, and background screening.
Findings
Deficiencies involving resident care elopement, medication labeling, staffing, and background screening.
Deficiencies (4)
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
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