Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2017 to 2025 with deficiency history.
Findings
Across all inspections, the facility mostly had no deficiencies cited, with one complaint inspection on 01/06/2020 citing deficiencies that were later corrected.
Report Facts
Inspections on page: 13
Inspection Report
Complaint
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Routine
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication storage, infection prevention and control programs, and proper use of personal protective equipment (PPE) in the facility.
Findings
The facility was found deficient in securely storing medications for one resident and failing to implement effective infection control measures, including improper use of PPE during care for residents on Enhanced Barrier Precautions and improper storage of respiratory equipment for one resident.
Deficiencies (2)
Failed to ensure medications and biologicals were securely stored for one resident (Resident #43).
Failed to provide and implement an infection prevention and control program, including failure to use appropriate PPE for residents on Enhanced Barrier Precautions and improper storage of respiratory equipment.
Report Facts
Residents affected: 1
Residents affected: 3
Residents observed on respiratory therapy: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse/Unit Manager | Confirmed medications were not securely stored for Resident #43 |
| Director of Nursing | Stated expectation that residents follow medication storage rules and staff use appropriate PPE | |
| Staff B | Registered Nurse (RN) | Observed not using PPE during wound care for Resident #49 and admitted error |
| Staff E | RN Clinical Educator | Observed not using PPE during wound care for Resident #49 and acknowledged error |
| Staff D | Licensed Practical Nurse (LPN) | Observed not using PPE during enteral feeding for Resident #84 and admitted error |
| Staff C | Licensed Practical Nurse (LPN) | Stated nebulizer should have been placed in a bag for storage |
| Staff F | Certified Nursing Assistant (CNA) | Observed not wearing gown during care and transfer of Resident #113 and admitted error |
| Staff G | Certified Nursing Assistant (CNA) | Observed not wearing gown during care of Resident #113 and admitted error |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 24, 2024
Visit Reason
The inspection was conducted based on complaints regarding medication administration, IV fluid administration, and infection control practices at the facility.
Complaint Details
The complaint investigation revealed issues with medication administration not respecting resident preferences, improper IV catheter site care including undated and soiled dressings, lack of orders for flushing and monitoring, and inadequate infection control measures such as missing Enhanced Barrier Precautions signage and PPE availability near resident rooms.
Findings
The facility failed to administer medications according to resident preference, failed to properly assess and maintain IV catheter sites including dressing changes and flushing, and failed to ensure Enhanced Barrier Precautions and PPE availability for residents with IV sites.
Deficiencies (3)
Failed to administer medications in accordance with resident preference for one of three residents sampled.
Failed to assess, maintain in a sanitary manner, and provide dressing changes for one of three residents with central intravenous catheters.
Failed to provide and implement an infection prevention and control program ensuring Enhanced Barrier Precautions and PPE availability for residents with IV sites.
Report Facts
Residents sampled for medication administration: 3
Residents sampled for IV catheter care: 3
Residents sampled for infection control: 3
PICC dressing change frequency: 7
Length of PICC catheter: 45
Duration of antibiotic order: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Cared for Resident #1 and provided information about medication order changes. |
| Director of Nursing (DON) | Director of Nursing | Provided information about medication orders, IV care policies, and infection control procedures. |
| Staff D | Advanced Practice Registered Nurse (APRN) | Resident #1's provider who discussed medication intolerance and order adjustments. |
| Staff A | Licensed Practical Nurse (LPN) | Reported on Resident #5's IV catheter condition and infection status. |
| Staff C | Licensed Practical Nurse (LPN) | Provided information about Enhanced Barrier Precautions policy. |
Inspection Report
Routine
Deficiencies: 6
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring that drugs and biologicals are labeled and stored securely in locked compartments and medication carts.
Findings
The facility failed to ensure proper medication storage in multiple medication carts and units, with observations of unlocked treatment carts, medication left on the floor, loose pills in medication carts, and unlabeled medication packages. Staff interviews and policy reviews confirmed these issues and the expectation for secure medication storage.
Deficiencies (6)
Medication stored in unlocked treatment carts and medication carts.
Medication found on the floor outside a resident room.
Loose pills found in medication carts.
Medication not labeled with resident name or prescription found in medication cart.
Medication carts not cleaned properly, with dirt, debris, and spilled liquid medication.
Medication storage compartments and carts not locked when not in use.
Report Facts
Loose pills: 5
Loose pills: 13
Blister packs: 6
Intravenous medications: 2
Topical medications: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding unlocked treatment cart and medication handling |
| Staff H | Licensed Practical Nurse (LPN) | Removed pill from floor and commented on proper disposal |
| Staff F | Licensed Practical Nurse (LPN) | Confirmed no loose pills should be in medication cart and responsible for cleaning |
| Staff D | Registered Nurse (RN) | Observed medication cart with loose pills and spilled medication |
| Staff G | Registered Nurse/Unit Manager (RN/UM) | Interviewed about medication cart checks and proper storage |
| Regional Director of Nursing | Interviewed regarding medication storage policies and confirmed issues |
Inspection Report
Complaint
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Re-Inspection
Census: 115
Deficiencies: 14
Date: Dec 2, 2022
Visit Reason
The visit was a re-inspection survey conducted to follow up on previously cited deficiencies related to resident care, infection control, medication management, and quality assurance.
Findings
The facility was found to have multiple deficiencies including inaccurate advance directives documentation, failure to complete significant change assessments for hospice residents, incomplete care plans for hearing aids and pain management, delayed Activities of Daily Living (ADL) care, inadequate activities for residents with sensory deficits, failure to coordinate hospice care, unsafe resident transfers resulting in injury, missed call light responses, unsecured medications, lack of dental services, failure to maintain infection control standards including scabies management, and an ineffective Quality Assurance program.
Deficiencies (14)
Failed to ensure accurate advance directive documentation and code status for Resident #323.
Failed to complete a significant change assessment when Resident #16 elected hospice benefit.
Failed to develop and implement comprehensive care plans for hearing aids and pain for Residents #21 and #98.
Failed to provide timely Activities of Daily Living (ADL) care for Residents #52, #59, #92, and #323.
Failed to provide appropriate activities for Resident #224 with vision sensory deficits.
Failed to ensure coordination of care between facility and hospice for Resident #16.
Failed to ensure safe resident transfer resulting in fractured right arm for Resident #50 and failed to assess and document staff/resident incident for Resident #322.
Failed to provide safe and appropriate pain management for Residents #98 and #221.
Failed to provide enough nursing staff to meet resident needs and have licensed nurse in charge on each shift; call light response delays noted.
Failed to ensure medications were stored securely and inaccessible by unauthorized persons for Residents #324 and #52.
Failed to provide or obtain dental services or inform Resident #43 of dental services availability.
Failed to maintain infection prevention and control standards related to scabies management, cleaning of shared equipment, hand hygiene during wound care, respiratory equipment sanitation, and urinary catheter drainage bag maintenance for multiple residents.
Failed to maintain accurate and consistent advance directive and code status documentation for Resident #1, resulting in conflicting orders and confusion.
Failed to maintain a functioning Quality Assurance Committee to effectively monitor and implement corrective actions for identified deficiencies.
Report Facts
Residents affected: 44
Staff CNAs working: 5
Facility census: 115
Days waiting for physician to sign DNR: 17
BIMS score: 12
BIMS score: 10
BIMS score: 15
BIMS score: 11
BIMS score: 14
BIMS score: 15
BIMS score: 3
BIMS score: 8
Pain level: 10
Pain level: 9
Medication doses missed: 2
Medication doses missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding Resident #323's code status discrepancy and medication observations |
| Social Service Director | Social Service Director | Interviewed regarding Resident #323's code status and hospice care coordination |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #323's code status, hospice care coordination, medication management, and infection control |
| Staff B | Registered Nurse | Interviewed regarding advance directive binder and physician orders for Resident #323 |
| Staff C | Licensed Practical Nurse | Interviewed regarding Resident #21 hearing aids and Resident #98 pain medication incident |
| Staff V | Certified Nursing Assistant | Interviewed regarding Resident #21 hearing aids and infection control practices |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Interviewed regarding Resident #21 care plan and hearing aid use |
| Staff J | Registered Nurse/MDS Nurse | Interviewed regarding hospice care coordination for Resident #16 |
| Staff K | Licensed Practical Nurse | Interviewed regarding hospice binder and Resident #50 transfer incident |
| Staff O | Certified Nursing Assistant | Interviewed regarding Resident #50 transfer incident |
| Staff M | Certified Nursing Assistant | Interviewed regarding call light response and catheter care |
| Staff N | Certified Nursing Assistant | Interviewed regarding call light response and catheter care |
| Staff R | Licensed Practical Nurse | Interviewed regarding scabies diagnosis and infection control |
| Staff U | Certified Nursing Assistant | Interviewed regarding cleaning of blood pressure cuff and shower chairs |
| Staff X | Registered Nurse/Wound Care Nurse | Observed wound care and interviewed regarding hand hygiene |
| Staff Y | Certified Nursing Assistant | Interviewed regarding scabies isolation and laundry |
| Staff Z | Housekeeping | Interviewed regarding cleaning supplies and procedures |
| Clinical Education Specialist | Clinical Education Specialist | Interviewed regarding terminal cleaning of scabies room |
| Staff T | Unit Manager | Interviewed regarding terminal cleaning and scabies management |
| Staff AA | Licensed Practical Nurse | Interviewed regarding CPAP tubing maintenance |
| Social Services Director | Social Services Director | Interviewed regarding dental services coordination |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding advance directive discrepancy and quality assurance |
| Advanced Registered Nurse Practitioner | ARNP | Interviewed regarding code status determination and orders for Resident #1 |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning procedures for scabies room |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding scabies room cleaning and infection control |
Inspection Report
Complaint
Deficiencies: 0
Date: May 31, 2022
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 6, 2021
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 24, 2021
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Complaint
Deficiencies: 0
Date: Feb 24, 2020
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Complaint
Deficiencies: 1
Date: Jan 6, 2020
Visit Reason
One deficiency found related to medication storage and disposal (Tag A0055, Class 3).
Findings
One deficiency found related to medication storage and disposal (Tag A0055, Class 3).
Deficiencies (1)
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Inspection Report
Complaint
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
Inspection Report
Deficiencies: 0
Date: Oct 4, 2017
Visit Reason
No deficiencies found.
Findings
No deficiencies found.
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