Inspection Reports for Park Meadows Health and Rehabilitation Center
FL, 32608
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 1
Date: Mar 29, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, including proper housekeeping and sanitation.
Findings
The facility failed to maintain an orderly and sanitary environment in all four hallways (100, 200, 300, 400), with observed trash, debris, and unsanitary conditions throughout the inspection. Housekeeping personnel were not present during the morning of the inspection, and the daily cleaning schedule was not followed as expected.
Deficiencies (1)
Failure to ensure an orderly and sanitary environment in 4 hallways with buildup of trash and debris, absence of housekeeping carts, and presence of dried liquid on walls.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed unclean and unsanitary environment and stated housekeeping was not following the daily cleaning schedule. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including resident care, dietary services, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, incomplete care plans, medication administration errors, failure to provide appropriate therapeutic diets, inadequate infection control practices, and failure to implement effective quality assurance processes. An Immediate Jeopardy was identified related to serving a resident a diet inconsistent with physician orders, which was subsequently removed after corrective actions.
Deficiencies (11)
Failed to provide a clean, orderly, and comfortable environment in shower rooms and memory care unit.
Failed to implement comprehensive care plans for residents at risk for falls and incontinence.
Failed to ensure residents received blood pressure medication as prescribed.
Served inappropriate therapeutic diet to resident, resulting in Immediate Jeopardy due to risk of choking and aspiration.
Failed to provide enough food/fluids to maintain residents' health for two residents.
Failed to provide timely laboratory services for medication review.
Failed to ensure food was served at an appetizing temperature.
Failed to ensure medical records were accurately documented for a resident's nutrition.
Failed to ensure staff performed hand hygiene during medication administration and sanitized reusable medical equipment; failed to provide clean storage for clean linen.
Failed to utilize Quality Assessment and Performance Improvement (QAPI) process effectively to address deficiencies related to therapeutic diets and abuse/neglect.
Failed to administer the facility in a manner that enables effective and efficient use of resources, including failure to implement policies related to therapeutic diets.
Report Facts
Weight loss: 17.29
Weight loss: 8.83
Staff reeducation count: 227
Total staff: 233
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse | Named in therapeutic diet error involving serving hot dog to Resident #45 |
| Staff I | Registered Nurse | Named in therapeutic diet error involving serving hot dog to Resident #45 |
| Staff K | Certified Nursing Assistant | Named in therapeutic diet error involving serving hot dog to Resident #45 |
| Director of Nursing | Provided multiple interviews regarding medication administration and diet errors | |
| Administrator | Provided interviews regarding facility administration and diet error incident | |
| Registered Dietitian #1 | Registered Dietitian | Provided expert opinion on diet errors and staff education |
| Medical Director | Provided interview regarding therapeutic diet incident and resident risk | |
| Staff A | Certified Nursing Assistant | Observed failing to sanitize vital sign machine between residents |
| Staff B | Licensed Practical Nurse | Observed failing to perform hand hygiene during medication administration |
| Staff Q | Cook | Named in therapeutic diet error involving serving hot dog to Resident #45 |
| Staff R | Speech Therapist | Provided interview regarding risks of inappropriate diet for Resident #45 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 1, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to protect residents from medical neglect, specifically related to insulin administration and failure to notify physicians of changes in condition.
Complaint Details
The complaint investigation revealed substantiated findings of immediate jeopardy related to failure to administer long-acting insulin as ordered and failure to notify physicians of changes in condition for multiple residents. Immediate jeopardy was removed after the facility implemented corrective actions including audits, education, and a plan of correction.
Findings
The facility failed to protect residents from medical neglect by not notifying physicians of elevated blood sugars and failing to follow physician orders for long-acting insulin administration for multiple residents. The facility also failed to notify the physician of a change in condition for a resident with a resistant urinary tract infection. The administration failed to effectively implement a QAPI plan and did not identify medication errors related to insulin administration.
Deficiencies (4)
Failure to notify physician of elevated blood sugars and failure to follow physician orders for long-acting insulin administration for multiple residents.
Failure to notify physician of changes in condition for Resident #13 and failure to follow physician orders for long-acting insulin for Residents #100, #4, and #5.
Failure to notify physician of a change in condition for Resident #1 related to resistant urinary tract infection.
Failure of facility administration to use resources effectively and efficiently to maintain highest practicable physical wellbeing of residents, including failure to identify medication errors and ensure physician notification.
Report Facts
Days insulin held per parameters: 16
Days insulin held per parameters: 7
Days insulin held per parameters: 10
Days insulin held per parameters: 7
Days insulin held per parameters: 5
Days insulin held per parameters: 6
Blood sugar readings: 461
Blood sugar readings: 424
Blood sugar readings: 527
Blood sugar readings: 542
Blood sugar readings: 531
Urine culture colony count: 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Documented insulin held per parameters for Resident #100 |
| Staff B | Licensed Practical Nurse | Documented insulin held per parameters for Residents #100, #4, and #5; admitted holding insulin without notifying physician |
| Staff C | Licensed Practical Nurse | Documented insulin not required for Residents #100, #4, and #5 |
| Staff D | Licensed Practical Nurse | Admitted holding insulin based on short acting insulin scale and not following doctor's orders |
| Staff H | Licensed Practical Nurse | Admitted holding long-acting insulin without notifying physician |
| Staff I | Licensed Practical Nurse | Admitted holding long-acting insulin without notifying physician |
| Staff J | Regional Nurse Consultant | Conducted audits and education on insulin administration |
| Staff K | Regional Nurse Consultant | Stated no evidence of physician notification for insulin not administered |
| Staff N | Licensed Practical Nurse | Reported not trained on long-acting insulin until day of interview |
| Staff O | Licensed Practical Nurse | Reported not trained on types of insulin until day of interview |
| Staff P | Registered Nurse | Reported not trained on long-acting insulin until day of interview |
| Staff Q | Licensed Practical Nurse | Reported training on insulin types and administration only on day of interview |
| Medical Director | Not aware nurses were holding long-acting insulin; stated nurses should notify if insulin not administered | |
| Administrator | Acknowledged failure to identify insulin administration issues during audits and failure to notify physicians | |
| Director of Nursing | Not aware of insulin administration issues; responsible for supervision of medication administration | |
| Staff B | Registered Nurse | Called physician about critical lab but did not follow up with sensitivities |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, respiratory care, medication storage and administration, food safety, medical record accuracy, infection control, and quality assurance.
Findings
The facility failed to ensure accurate resident assessments, proper respiratory care, secure medication storage, complete medical records, safe food storage, adherence to insulin administration orders, and proper infection control during tracheostomy care. The Quality Assurance and Performance Improvement program failed to identify and correct medication administration errors, including holding long-acting insulin without physician notification.
Deficiencies (7)
Failed to ensure resident assessments accurately reflected discharge status for 3 of 4 residents reviewed.
Failed to provide safe and appropriate respiratory care for 2 of 11 residents reviewed for respiratory services.
Failed to ensure drugs and biologicals were secured and stored properly in the facility.
Failed to ensure food was stored in accordance with professional standards for food service safety.
Failed to ensure resident records were complete and accurate for 2 of 4 residents reviewed for assistance with activities of daily living.
Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in failure to identify medication errors and failure to follow physician orders for insulin administration for multiple residents.
Failed to ensure staff followed accepted infection control practice standards during tracheostomy care for 1 of 2 residents with tracheostomy.
Report Facts
Residents reviewed for discharge status: 4
Residents affected by inaccurate discharge assessments: 3
Residents reviewed for respiratory services: 11
Residents affected by respiratory care deficiencies: 2
Residents affected by medication storage deficiencies: 4
Residents reviewed for assistance with activities of daily living: 4
Residents affected by incomplete medical records: 2
Licensed nursing staff trained on insulin administration: 39
Residents affected by insulin administration errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse, Lead MDS | Interviewed regarding inaccurate discharge MDS coding |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding discharge assessments, respiratory care, medication storage, and insulin administration |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed and observed regarding respiratory care and insulin administration |
| Infection Preventionist | Infection Preventionist | Interviewed regarding respiratory care and infection control |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed regarding shower documentation |
| Staff F | Visiting Kitchen Manager | Interviewed regarding food storage |
| Staff J | Regional Nurse Consultant | Interviewed regarding insulin administration and quality assurance |
| Staff H | Licensed Practical Nurse (LPN) | Interviewed regarding insulin administration |
| Staff I | Licensed Practical Nurse (LPN) | Interviewed regarding insulin administration |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed and observed regarding tracheostomy care and insulin administration |
| Medical Director | Medical Director | Interviewed regarding insulin administration concerns |
| Administrator | Administrator | Interviewed regarding insulin administration and quality assurance |
| Staff K | Regional Nurse Consultant | Interviewed regarding insulin administration |
| Staff G | Licensed Practical Nurse (LPN) | Documented insulin administration on MAR |
Inspection Report
Deficiencies: 1
Date: Mar 4, 2023
Visit Reason
The inspection was conducted to assess compliance with food storage and safety standards in the facility's nourishment rooms.
Findings
The facility failed to ensure that food stored for resident consumption in 2 of 3 nourishment rooms was stored according to professional food service safety standards, including unlabeled and outdated food items.
Deficiencies (1)
Food stored in nourishment rooms was not properly labeled or dated, including eight health shakes without pulled/thawed/use by date, an unopened/unlabeled package of deli meat with an expired date, and four outdated sandwiches.
Report Facts
Health shakes without date: 10
Outdated sandwiches: 4
Expired deli meat package: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed food labeling and dating requirements and responsibility of dietary staff |
| Administrator | Administrator | Participated in nourishment room tour and confirmed findings |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Feb 18, 2022
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with healthcare regulations and standards at Park Meadows Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide ordered nutritional supplements to a resident, improper care and documentation for residents receiving enteral nutrition, lack of pharmacist review documentation for medication regimen, improper labeling and storage of medications, insufficient qualifications of the Culinary Service Manager, and unsanitary food storage conditions in the kitchen and nourishment rooms.
Deficiencies (6)
Failed to provide a resident with physician-ordered frozen nutritional treats leading to significant weight loss.
Failed to ensure appropriate treatment and documentation for residents receiving enteral nutrition, including missing labeling and incorrect formula infusion.
Failed to ensure attending physician documented review and action on pharmacist's medication recommendations.
Failed to ensure drugs and biologicals were properly labeled with opened dates and stored in locked compartments; expired medications found.
Failed to employ a qualified Culinary Service Manager with required certifications or educational background.
Failed to store food in a sanitary manner; observed black and grey substance on ice machine and unlabeled, undated food items in nourishment room.
Report Facts
Residents reviewed for nutrition: 7
Total residents sampled: 41
Weight loss percentage: 11.03
Weight loss percentage: 7
Formula bag volume: 900
Formula bag volume: 1000
Formula infused volume: 200
Formula balance volume: 800
Formula infusion rate: 70
Formula infusion duration: 20
Medication count: 22
Hiring date: Jul 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Interviewed regarding enteral feeding bag labeling and infusion issues for Residents #48 and #488. |
| Culinary Service Manager | Interviewed regarding failure to provide nutritional treats and qualifications; confirmed not a Certified Dietary Manager. | |
| Director of Nursing | Interviewed regarding lack of physician documentation on pharmacist recommendations for Resident #25. | |
| Staff A | Licensed Practical Nurse | Observed with medication cart issues including unlabeled ointment and insulin. |
| Staff B | Licensed Practical Nurse | Observed with medication cart issues including expired narcotic and unlabeled insulin. |
| Staff C | Licensed Practical Nurse | Observed with medication cart issues including unlabeled eye drops and insulin past expiration. |
| Staff D | Licensed Practical Nurse | Observed with medication cart issues including unlabeled insulin. |
| Unit Manager of Station 1 | Interviewed regarding insulin storage and refrigeration issues. | |
| Administrator | Confirmed Culinary Service Manager lacked required certification and educational background. |
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