Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 10, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a 30-day discharge notice and refusal to allow a resident (Resident #1) to return to the facility following hospitalization under a [NAME] Act transfer.
Findings
The facility failed to provide the required 30-day discharge notice for Resident #1 and did not permit him to return after hospitalization despite his and his representative's wishes. Resident #1 experienced emotional distress and a suicide attempt prior to discharge. The facility decided not to readmit him due to safety concerns related to his behavior. The facility's policies and procedures regarding transfer, discharge, and resident return were reviewed and found to have been violated.
Complaint Details
The complaint involved Resident #1 who was discharged without the required 30-day notice and was not allowed to return to the facility after hospitalization under a [NAME] Act. The resident attempted suicide prior to discharge. The facility refused readmission citing safety concerns. The Long Term Care Ombudsman intervened, advising the facility to accept the resident back, but the facility refused. Interviews with the resident, his spouse, hospital staff, and facility staff confirmed these findings.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide timely 30-day discharge notice to Resident #1 before transfer. | Level of Harm - Actual harm |
| Failure to permit Resident #1 to return to the facility after hospitalization despite his eligibility and desire to return. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for facility-initiated discharges: 2
Total residents sampled: 4
Resident #1 discharge date: Oct 23, 2024
Bed hold maximum days: 8
Resident #1 length of stay at facility: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding decision to not readmit Resident #1 and discharge procedures | |
| Director of Nursing | Interviewed alongside Administrator regarding Resident #1's care and discharge | |
| Long Term Care Ombudsman A | Interviewed regarding advocacy for Resident #1's return to facility | |
| Clinical Supervisor | Receiving hospital Clinical Supervisor | Interviewed about Resident #1's hospital stay and facility refusal to readmit |
| Psychiatric Counselor | Receiving hospital Psychiatric Counselor | Interviewed about Resident #1's mental health status and facility refusal to readmit |
Inspection Report
Routine
Census: 104
Deficiencies: 3
Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, food safety, and sanitation in the facility, including resident care, food service, and waste disposal.
Findings
The facility failed to provide appropriate nail care for one resident, failed to maintain ice machines in sanitary condition risking contamination, and failed to properly dispose of garbage and refuse, creating unsanitary conditions and pest risks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide appropriate assistance with nail care for one resident, including cleaning under nails. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store and distribute ice in accordance with professional standards; presence of biofilm (pink slime) on ice machine. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure waste and refuse were properly disposed of in dumpsters, resulting in unsanitary conditions and risk of pests. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in facility: 104
Residents affected by nail care deficiency: 1
Residents affected by ice machine deficiency: 103
Dumpster count inspected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding responsibility for residents' nail care | |
| Certified Nursing Assistant (CNA) B | Interviewed confirming CNA responsibilities for nail care | |
| Long Term Care Unit Manager (LTCUM) | Interviewed confirming nail care standards and observations | |
| Certified Dietary Manager (CDM) | Interviewed and observed ice machine and dumpster conditions | |
| Maintenance Director (MD) | Interviewed regarding ice machine maintenance and dumpster conditions |
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident privacy during medication administration and to evaluate medication error rates.
Findings
The facility failed to ensure privacy for residents during medication administration for two residents observed, and failed to maintain a medication error rate below 5%, with an error rate of 5.714% based on 2 errors out of 35 opportunities.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure privacy during medication administration for Residents #85 and #5, with doors left open and privacy curtains not pulled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rates were less than 5%, with 2 errors out of 35 opportunities resulting in a 5.714% error rate. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed during medication administration: 27
Medication error opportunities: 35
Medication errors: 2
Medication error rate: 5.714
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) A | Observed failing to provide privacy during blood glucose monitoring and insulin administration for Resident #85 | |
| Licensed Practical Nurse (LPN) B | Observed failing to provide privacy during blood glucose monitoring and insulin administration for Resident #5 | |
| Licensed Practical Nurse (LPN) C | Observed failing to provide privacy and committing medication errors during administration to Resident #5 | |
| LPN D/Unit Manager | Contacted physician regarding Resident #5's blood sugar and medication orders |
Inspection Report
Routine
Deficiencies: 5
Feb 27, 2020
Visit Reason
The inspection was conducted based on observations and staff interviews to assess the facility's compliance with professional standards for food service safety, specifically regarding food preparation, distribution, and serving practices.
Findings
The facility failed to maintain proper food service safety standards, with observations of black substance and mold growth in the kitchen dishwashing area, dirty serving utensils, and damaged equipment. Additionally, the facility lacked a cleaning schedule for power washing the dishroom walls, despite staff statements about cleaning practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Black substance and mold growth on walls and dish rack holders in the kitchen dishwashing room. | Level of Harm - Minimal harm or potential for actual harm |
| Serving scoops stored with dried food debris and can opener impacted. | Level of Harm - Minimal harm or potential for actual harm |
| Plate Lowerators holding clean plates with spillage and food debris. | Level of Harm - Minimal harm or potential for actual harm |
| Base of door leading out of cleaning equipment room missing kick plate and covered with black growth. | Level of Harm - Minimal harm or potential for actual harm |
| Facility had no cleaning schedule for power washing dishroom walls despite staff statements about cleaning frequency. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of initial observation: Feb 24, 2020
Date of final observation: Feb 27, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Interviewed regarding cleaning practices and mold problem in kitchen | |
| Administrator | Interviewed about replacement door and presence during photographic evidence | |
| Dietary aide | Interviewed about cleaning frequency of dishwashing area walls |
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