Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2013 to 2025 with deficiency history and inspection statuses.
Findings
Across multiple inspections, the facility had many inspections with no deficiencies, several with deficiencies cited, and some with deficiencies corrected. The most recent inspections show no deficiencies.
Report Facts
Inspections on page: 41
Inspection Report
Complaint
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of Resident #6 by a staff member.
Complaint Details
The complaint involved an incident on 9/14/24 where Resident #6 spat at Staff B, who spat back and held the resident's hands down during care. Staff A witnessed the incident but did not report it until 9/16/24, resulting in delayed reporting to authorities. The allegation was substantiated based on interviews and staff admissions.
Findings
The facility failed to protect Resident #6 from physical abuse by Staff B, who admitted to holding down the resident's hands and spitting back at the resident during care. Additionally, the facility failed to report the alleged abuse incident within the required 2-hour timeframe.
Deficiencies (2)
F 0600: The facility failed to protect Resident #6 from physical abuse by a staff member who spat at the resident and held down the resident's hands during care. The resident exhibited combative behavior and spitting, but staff response was inappropriate.
F 0609: The facility failed to report suspected abuse involving Resident #6 immediately or within 2 hours as required, delaying notification to the state agency and law enforcement by approximately 40 hours.
Report Facts
Hours delayed in reporting abuse: 40
Date of incident: Sep 14, 2024
Date of report: Sep 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Admitted to holding down Resident #6's hands and spitting back at the resident during care |
| Staff A | Certified Nursing Assistant (CNA) | Witnessed the abuse incident and delayed reporting it by 2 days |
| Staff D | Licensed Practical Nurse (LPN) | Charge Nurse on shift who advised Staff A to report the incident |
| Nursing Home Administrator (NHA) | Interviewed regarding the incident and reporting delays | |
| Director of Nursing (DON) | Interviewed regarding the incident and reporting delays | |
| Regional Health Care Director (RHCD) | Interviewed regarding the incident and reporting delays |
Inspection Report
Complaint
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Monitor
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
No deficiencies found during this monitor inspection.
Findings
No deficiencies found during this monitor inspection.
Inspection Report
Deficiencies: 6
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including care planning, pressure ulcer prevention, respiratory care, dialysis care, trauma-informed care, and caregiver competencies.
Findings
The facility was found deficient in multiple areas including inaccurate care plans for advanced directives, failure to ensure pressure relieving boots were used, lack of physician orders for respiratory devices, inadequate monitoring of dialysis fistula, failure to identify trauma triggers for a resident with PTSD, and employing a private caregiver without proper competencies for resident care.
Deficiencies (6)
F 0657: The facility failed to ensure an accurate care plan was in place related to Advanced Directives for one resident (#101) out of 40 sampled residents.
F 0686: The facility failed to ensure pressure relieving boots were applied to prevent worsening of a pressure wound for one resident (#101).
F 0695: The facility failed to ensure identification and monitoring of a BIPAP machine was in place for one resident (#6).
F 0698: The facility failed to ensure ongoing assessment and monitoring of the dialysis fistula before and after dialysis treatments for one resident (#37).
F 0699: The facility failed to ensure one resident (#72) with PTSD was assessed to identify triggers which may re-traumatize the resident.
F 0726: The facility failed to ensure a paid caregiver for one resident (#205) had specific competencies and skill sets necessary to care for the resident's care needs.
Report Facts
Residents sampled: 40
Residents sampled for pressure wounds: 1
Residents sampled for respiratory care: 1
Residents sampled for dialysis care: 3
Dialysis communication forms reviewed: 6
Dialysis days per week: 3
Private caregiver hours: 7
Private caregiver hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | RN, Assistant Director of Nursing | Named in dialysis fistula monitoring deficiency and interview |
| Staff E | LPN | Named in dialysis fistula bleeding incident and interview |
| Staff G | CNA | Named in pressure ulcer care and private caregiver interview |
| Staff F | Assistant Social Worker | Named in advanced directives care plan interview |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including advanced directives, pressure ulcer care, respiratory care, dialysis care, trauma informed care |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding advanced directives, private caregiver competency, and trauma informed care |
| Staff D | Certified Nursing Assistant | Interviewed regarding dialysis education and bleeding response |
Inspection Report
Standard
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
One Class 3 deficiency related to Alzheimer Disease/Dementia training.
Findings
One Class 3 deficiency related to Alzheimer Disease/Dementia training.
Deficiencies (1)
Tag CZ875 — ALZHEIMER DISEASE/DEMENTIA; TRAINING
Inspection Report
Standard
Deficiencies: 4
Date: Jan 18, 2024
Visit Reason
Five Class 3 deficiencies related to admissions, medication assistance, and staff training.
Findings
Five Class 3 deficiencies related to admissions, medication assistance, and staff training.
Deficiencies (4)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0086 — TRAINING - ADRD
Inspection Report
Complaint
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: May 18, 2023
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Dec 27, 2022
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
No deficiencies found during this complaint inspection.
Findings
No deficiencies found during this complaint inspection.
Inspection Report
Routine
Deficiencies: 5
Date: Feb 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, laboratory services, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering catheter drainage bags, failure to implement advance directive wishes timely, failure to implement care plans related to vision and hearing, a high medication error rate of 66.67%, and failure to obtain and verify laboratory results for a physician ordered urinalysis.
Deficiencies (5)
F 0550: The facility failed to treat residents with respect and dignity by not covering the urine drainage bag of Resident #230 with a privacy cover on two of four survey days.
F 0578: The facility failed to ensure advance directive wishes were implemented for Resident #35, resulting in a delay in recognizing and following a DNR order.
F 0656: The facility failed to implement the care plan for Resident #34 by not offering eyeglasses on three observed days, resulting in failure to identify the resident's eyeglasses were missing.
F 0759: The facility failed to ensure medication error rates were below 5%, with 18 errors in 27 medication administration opportunities, constituting a 66.67% error rate.
F 0770: The facility failed to obtain and verify laboratory results for a physician ordered urinalysis for Resident #6, with no evidence the lab was completed or results reviewed.
Report Facts
Medication error rate: 66.67
Medication administration opportunities observed: 27
Medication errors identified: 18
Residents reviewed for advance directives: 83
Residents sampled for vision and hearing: 2
Inspection Report
Standard
Deficiencies: 8
Date: Feb 16, 2022
Visit Reason
Eight Class 3 deficiencies and one severity 2 deficiency related to medication records, staffing, training, and records.
Findings
Eight Class 3 deficiencies and one severity 2 deficiency related to medication records, staffing, training, and records.
Deficiencies (8)
Tag A0054 — MEDICATION - RECORDS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0082 — TRAINING - HIV/AIDS
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0161 — RECORDS - STAFF
Tag A0025 — RESIDENT CARE - SUPERVISION
Inspection Report
Complaint
Deficiencies: 4
Date: Dec 28, 2021
Visit Reason
Five Class 3 deficiencies related to admissions, training, and records.
Findings
Five Class 3 deficiencies related to admissions, training, and records.
Deficiencies (4)
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0160 — RECORDS - FACILITY
Tag A0162 — RECORDS - RESIDENT
Inspection Report
Routine
Deficiencies: 3
Date: Nov 19, 2020
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, food safety, sanitation, and environmental cleanliness standards at the nursing home.
Findings
The facility failed to maintain medication error rates below 5%, had issues with food temperature monitoring and sanitary storage of clean dishware, and did not ensure a clean and sanitary environment in at least one resident room. Multiple policy and procedural deficiencies were identified related to medication administration, food safety, and housekeeping.
Deficiencies (3)
F 0759: The facility did not ensure medication error rates were below 5%, resulting in a 16% error rate during medication administration observations involving two residents.
F 0812: The facility failed to ensure food temperatures were consistently taken and recorded before meal service and that clean dishware was stored under sanitary conditions in the kitchen.
F 0921: The facility did not maintain a clean and sanitary environment in one resident room, which had visible soil, sticky floors, and unclean furniture despite housekeeping policies requiring daily cleaning.
Report Facts
Medication error rate: 16
Medication administration sample size: 6
Food temperature logs missing entries: 11
Food temperature cold holding limit: 41
Food temperature hot holding limit: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in medication administration observation involving Resident #175. |
| Staff E | Registered Nurse (RN) | Named in medication administration observation involving Resident #55. |
| Staff M | Dietary Supervisor | Conducted kitchen tours and provided information on food temperature logs and sanitation. |
| Staff G | Dietary Supervisor | Conducted kitchen tour and explained food preparation process. |
| Staff H | Server | Observed taking food temperatures and maintaining temperature logs. |
| Certified Dietary Manager (CDM) | Provided information on food temperature logs, audits, and sanitation concerns. | |
| Staff D | Certified Nursing Assistant (CNA) | Observed assisting resident in unclean room. |
| Staff E | Registered Nurse (RN), Assistant Director of Nursing (ADON), Unit Manager (UM) | Interviewed regarding room cleanliness and housekeeping standards. |
| Housekeeping Director | Confirmed unsanitary conditions in resident room and housekeeping procedures. | |
| Director of Nursing (DON) | Confirmed unacceptable room condition and housekeeping deficiencies. | |
| Nursing Home Administrator (NHA) | Participated in QA process meeting regarding food safety and sanitation concerns. |
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