Deficiencies (last 10 years)
Deficiencies (over 10 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 1
Date: Aug 12, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safe and appropriate respiratory care, specifically oxygen therapy administration as ordered by physicians.
Findings
The facility failed to administer oxygen therapy as ordered for two residents, with oxygen concentrators set at higher or lower flow rates than prescribed. Nursing staff did not consistently check or adjust oxygen flow rates according to physician orders.
Deficiencies (1)
F 0695: The facility failed to provide oxygen therapy as ordered by the physician for two residents, with oxygen concentrators set incorrectly at 3.5 LPM instead of 1 LPM and 1.5 LPM instead of 2 LPM. Nurses did not verify or adjust oxygen flow rates as required during their shifts.
Report Facts
Residents reviewed for respiratory care: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) A | Checked resident #3's oxygen settings and confirmed failure to verify correct flow rate | |
| Assistant Director of Nursing (ADON) | Observed and acknowledged oxygen therapy deficiencies for resident #3 | |
| Licensed Practical Nurse (LPN) B | Assigned to resident #4 and confirmed oxygen flow rate was not checked or adjusted as ordered | |
| Director of Nursing (DON) | Stated nurses are expected to check oxygen flow rates at least every shift and ensure orders are followed |
Inspection Report
Standard
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
The facility has undergone numerous inspections including complaint, standard, and monitoring types with a mix of deficiency findings: some inspections cited deficiencies, others corrected them, and several had no deficiencies noted.
Report Facts
Inspections on page: 49
Inspection Report
Routine
Deficiencies: 7
Date: Jan 7, 2025
Visit Reason
Multiple Class 3 deficiencies related to licensure, admissions, resident care, medication assistance, staffing, and records were identified.
Findings
Multiple Class 3 deficiencies related to licensure, admissions, resident care, medication assistance, staffing, and records were identified.
Deficiencies (7)
Tag A0004 — LICENSURE - REQUIREMENTS
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0160 — RECORDS - FACILITY
Tag CZ821 — REPORTING REQUIREMENTS; ELECTRONIC SUBMISSION
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 31, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to honor resident bathing preferences, failure to provide a timely written summary of the baseline care plan, and failure to involve residents or their representatives in care plan development.
Complaint Details
The investigation was complaint-driven, focusing on resident rights violations related to bathing preferences, baseline care plan documentation, and care plan participation. The complaints were substantiated with findings.
Findings
The facility failed to honor resident #55's bathing preference for showers, instead providing bed baths. Resident #869 did not receive a timely written summary of her baseline care plan within 48 hours of admission. Resident #38 and/or her representative were not invited or involved in care plan meetings as required.
Deficiencies (3)
F 0561: The facility failed to honor resident #55's right to choose preferred bathing methods, providing bed baths instead of showers as preferred.
F 0655: The facility failed to provide a written summary of the baseline care plan within 48 hours of admission for resident #869.
F 0657: The facility failed to ensure resident #38 and/or her representative were invited or involved in the development of her care plan.
Report Facts
Residents reviewed: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) B | Provided explanation regarding resident #55 bathing preference | |
| Certified Nursing Assistant (CNA) A | Reported on shower scheduling and resident bathing preferences for resident #55 | |
| Director of Nursing (DON) | Confirmed bathing preference issues for resident #55 and care plan documentation issues | |
| Registered Nurse Minimum Data Set (MDS) Coordinator | Explained baseline care plan process and care plan meeting invitations | |
| Assistant Director of Nursing/Unit Manager (ADON/UM) | Acknowledged care plan meeting invitation and participation issues for resident #38 |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 3, 2024
Visit Reason
Routine inspection to assess compliance with care standards including pressure ulcer prevention, medication administration, and staffing adequacy.
Findings
The facility failed to notify physicians and family representatives of changes in condition related to pressure ulcers, failed to provide adequate pressure ulcer care resulting in actual harm, and had insufficient nursing and CNA staffing to meet resident care needs. Medication administration was frequently delayed beyond acceptable timeframes.
Deficiencies (4)
F580: The facility failed to notify the physician and resident representatives of changes in condition related to a Stage III pressure ulcer and surgical procedure for 1 of 4 residents reviewed for pressure injuries.
F686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 2 of 4 residents reviewed, resulting in actual harm including wound infections, hospitalization, and death.
F725: The facility failed to provide sufficient licensed nurses and CNAs to meet medication administration and personal care needs for residents on multiple floors.
F755: The facility failed to provide timely medication administration for 25 of 27 residents reviewed, with many medications given hours late beyond the acceptable 1-hour window before or after scheduled times.
Report Facts
Residents reviewed for pressure injuries: 27
Residents affected by notification failure: 1
Residents affected by pressure ulcer care failure: 2
Residents reviewed for ADL care and staffing: 27
Residents affected by staffing deficiencies: 3
Residents reviewed for medication administration: 27
Residents affected by medication delays: 25
Inspection Report
Monitor
Deficiencies: 0
Date: May 7, 2024
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Inspection Report
Complaint
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
Class 3 deficiency related to resident care rights and facility procedures.
Findings
Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Enforcement
Deficiencies: 2
Date: May 19, 2023
Visit Reason
The inspection was conducted due to a failure to provide cardiopulmonary resuscitation (CPR) in accordance with a resident's full code order, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to honor a resident's full code status by not initiating CPR when the resident was found unresponsive with no vital signs. The failure involved licensed nursing staff disregarding physician orders and resident wishes, leading to the resident's death. Immediate jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (2)
F 0600: The facility failed to protect a resident from neglect by not providing CPR per the resident's full code order, resulting in immediate jeopardy to resident health or safety.
F 0678: The facility failed to provide basic life support including CPR prior to EMS arrival, contrary to physician orders and resident's advance directives, resulting in immediate jeopardy.
Report Facts
Residents with full code orders: 14
Licensed nurses educated on CPR and policies: 22
Licensed nurses working who completed mock code drills: 19
Licensed nurses total: 23
Licensed nurses out of state: 1
Licensed nurses out of state for mock drills: 1
Licensed staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to initiate CPR despite full code order |
| RN Supervisor B | Registered Nurse Supervisor | Named in failure to initiate CPR and instruct LPN to start CPR |
| ADON D | Assistant Director of Nursing | Instructed to override RN Supervisor and start CPR |
| NP E | Advanced Practice Registered Nurse | Provided expert opinion that CPR should have been performed |
| Medical Director | Stated resident should have received CPR when found unresponsive |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 30, 2023
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to provide a homelike dining environment, inadequate care planning for a resident with swallowing problems, improper resident positioning during meals, food safety violations, improper garbage disposal, and failure to implement proper infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, triggered by concerns about meal service practices, care planning for a resident with swallowing difficulties, resident positioning during meals, food safety, garbage disposal, and infection control. The choking incident involving Resident #82 was substantiated, and the facility was found deficient in care planning and other areas.
Findings
The facility failed to provide a homelike dining environment by serving meals on trays in an institutional manner, did not develop a comprehensive care plan addressing swallowing problems for a resident who subsequently died from choking, improperly positioned residents during meals, failed to maintain food safety standards including improper food storage and temperature control, did not properly dispose of garbage, and staff failed to perform proper hand hygiene during meal service.
Deficiencies (6)
F 0584: The facility served residents meals on serving trays at the table in an institutional manner without removing plates and eating ware from the trays during three different meals.
F 0656: The facility failed to develop a comprehensive care plan including compensatory swallowing strategies for Resident #82, who had dysphagia and died after a choking incident.
F 0675: The facility failed to ensure three residents were positioned properly during meals, seating them at tables that were too high to maximize eating abilities.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper dish machine pressure, unlabeled bulk food, improper food temperatures, and lack of date-marking on refrigerated foods.
F 0814: The facility failed to properly dispose of garbage in the compactor, leaving uncovered garbage and a resident list exposed near the compactor.
F 0880: Staff failed to perform proper hand hygiene during two meal observations, risking infection spread to residents.
Report Facts
Residents eating in first floor dining room: 11
Residents eating in first floor dining room: 17
Dish machine hot water pressure: 10
Residents affected: 77
Residents affected: 11
Staff training attendance: 9
Staff training attendance: 13
Staff training attendance: 12
Inspection Report
Routine
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
Class 3 deficiency for staffing standards and unclassified deficiency for background screening clearinghouse.
Findings
Class 3 deficiency for staffing standards and unclassified deficiency for background screening clearinghouse.
Deficiencies (2)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Complaint
Deficiencies: 2
Date: Aug 18, 2021
Visit Reason
Class 3 deficiencies related to licensure requirements and resident care supervision.
Findings
Class 3 deficiencies related to licensure requirements and resident care supervision.
Deficiencies (2)
Tag A0004 — LICENSURE - REQUIREMENTS
Tag A0025 — RESIDENT CARE - SUPERVISION
Inspection Report
Routine
Deficiencies: 4
Date: May 20, 2021
Visit Reason
The facility underwent a routine inspection to assess compliance with regulatory standards related to resident environment, staffing, medication management, and food safety.
Findings
The inspection identified multiple deficiencies including failure to maintain clean and homelike resident rooms, failure to post daily nurse staffing hours timely, presence of expired medication in storage, and food safety issues such as improper refrigeration temperatures, malfunctioning freezer door, unclean ice machines, and a broken pressure gauge on the dishwashing machine.
Deficiencies (4)
F 0584: The facility failed to maintain walls and carpets in a clean, homelike manner in 3 of 44 resident rooms, with deep gashes on walls and multiple red stains on carpets not reported to maintenance.
F 0732: The facility failed to post daily nurse staffing hours accurately, with the posted form dated the previous day and not updated timely.
F 0755: The facility failed to remove expired medication from 1 of 4 medication carts, with two packages of expired Tramadol found in the medication cart for resident #18.
F 0812: The facility failed to monitor refrigeration temperatures, maintain freezer door seals, clean ice machines, and monitor pressure gauge on the high temperature dishwashing machine, risking food contamination and improper sanitization.
Report Facts
Resident rooms inspected: 44
Medication carts reviewed: 4
Expired Tramadol pills: 48
Refrigeration temperature: 50
Dishwashing machine temperatures: 148
Dishwashing machine temperatures: 160
Dishwashing machine temperatures: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding maintenance of walls and carpets | |
| Housekeeper D | Interviewed about carpet cleaning and reporting | |
| Housekeeping Director | Explained carpet cleaning efforts and communication with maintenance | |
| Director of Nursing | Director of Nursing (DON) | Acknowledged staffing form posting issues and medication expiration checks |
| Staffing Coordinator | Responsible for posting nurse staffing hours, failed to update form timely | |
| Registered Nurse C | Registered Nurse (RN) | Noted usual practice to notify supervisor of expired medications |
| Pharmacy Consultant | Pharmacist Consultant | Reviewed medication appropriateness and expiration monitoring |
| Dining Services Director | Dining Services Director (DSD) | Interviewed about refrigeration monitoring, ice machine cleaning, and dishwashing machine pressure gauge |
| Chef | Reported freezer door issues and ice build-up | |
| Dining Services Technician | Observed dishwashing machine temperatures and pressure gauge malfunction |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 15, 2021
Visit Reason
Multiple Class 3 and Class 4 deficiencies related to resident care supervision, elopement standards, staffing, training, and resident records.
Findings
Multiple Class 3 and Class 4 deficiencies related to resident care supervision, elopement standards, staffing, training, and resident records.
Deficiencies (6)
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0162 — RECORDS - RESIDENT
Inspection Report
Complaint
Deficiencies: 1
Date: Aug 27, 2020
Visit Reason
Class 3 deficiency related to resident care rights and facility procedures.
Findings
Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Deficiencies: 4
Date: Oct 7, 2019
Visit Reason
Class 3 and Class 4 deficiencies related to staffing standards, training, and background screening.
Findings
Class 3 and Class 4 deficiencies related to staffing standards, training, and background screening.
Deficiencies (4)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0086 — TRAINING - ADRD
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Routine
Deficiencies: 17
Date: Dec 19, 2018
Visit Reason
Multiple Class 3 and Class 4 deficiencies related to training, records, medication, staffing, and extended congregate care.
Findings
Multiple Class 3 and Class 4 deficiencies related to training, records, medication, staffing, and extended congregate care.
Deficiencies (17)
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Tag A0160 — RECORDS - FACILITY
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Tag A0162 — RECORDS - RESIDENT
Tag AE203 — ECC - STAFFING REQUIREMENTS
Tag AE210 — ECC - TRAINING
Inspection Report
Monitor
Deficiencies: 5
Date: Mar 27, 2018
Visit Reason
Class 3 deficiencies related to staffing standards and training.
Findings
Class 3 deficiencies related to staffing standards and training.
Deficiencies (5)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag AE210 — ECC - TRAINING
Inspection Report
Complaint
Deficiencies: 1
Date: Jan 30, 2018
Visit Reason
Class 3 deficiencies related to emergency plan approval.
Findings
Class 3 deficiencies related to emergency plan approval.
Deficiencies (1)
Tag A0181 — EMERGENCY PLAN APPROVAL
Inspection Report
Complaint
Deficiencies: 2
Date: Dec 5, 2016
Visit Reason
Class 3 deficiencies related to resident care supervision and resident records.
Findings
Class 3 deficiencies related to resident care supervision and resident records.
Deficiencies (2)
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0162 — RECORDS - RESIDENT
Inspection Report
Routine
Deficiencies: 3
Date: Dec 5, 2016
Visit Reason
Class 3 deficiencies related to medication records, labeling, and resident contracts.
Findings
Class 3 deficiencies related to medication records, labeling, and resident contracts.
Deficiencies (3)
Tag A0054 — MEDICATION - RECORDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0167 — RESIDENT CONTRACTS
Inspection Report
Monitor
Deficiencies: 6
Date: Sep 29, 2014
Visit Reason
Class 3 and Class 4 deficiencies related to staffing, training, documentation, and background screening.
Findings
Class 3 and Class 4 deficiencies related to staffing, training, documentation, and background screening.
Deficiencies (6)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Tag AE210 — ECC - TRAINING
Tag AZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES
Inspection Report
Monitor
Deficiencies: 6
Date: Feb 26, 2014
Visit Reason
Class 3 deficiencies related to staff in-service training, HIV/AIDS training, medication assistance, do not resuscitate orders training, documentation, and extended congregate care training.
Findings
Class 3 deficiencies related to staff in-service training, HIV/AIDS training, medication assistance, do not resuscitate orders training, documentation, and extended congregate care training.
Deficiencies (6)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Tag AE210 — ECC - TRAINING
Inspection Report
Monitor
Deficiencies: 2
Date: Mar 13, 2013
Visit Reason
Class 3 deficiencies related to staff in-service training and do not resuscitate orders training.
Findings
Class 3 deficiencies related to staff in-service training and do not resuscitate orders training.
Deficiencies (2)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
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