Inspection Report Summary
The most recent inspection on April 24, 2025, identified multiple deficiencies related to resident dignity during meal service, care planning, pressure injury management, infection control, medication administration, activity engagement, vision care, nutrition, and facility maintenance. Earlier inspections showed a pattern of environmental maintenance issues, medication administration concerns, and lapses in resident care and safety, including a substantiated complaint investigation in February 2024 involving a fall from a broken mechanical lift that caused injury. Inspectors cited recurring themes of inadequate environment upkeep, incomplete or untimely care planning, and insufficient staff competencies in medication and equipment use. Complaint investigations were substantiated in 2024 regarding neglect and safety protocol failures, while other complaints were unsubstantiated or not noted. The inspection history indicates ongoing challenges with facility maintenance and care processes, with no clear improvement trend in recent reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 13
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, advance directives, care planning, pressure injury care, infection control, nutrition, activities, medication administration, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, untimely physician signatures on DNR orders, incomplete care plans, inadequate pressure injury assessment and care, failure to complete PASRR Level II referral for a resident with serious mental illness, insufficient activity engagement, improper medication administration practices, failure to assist with vision care, infection prevention and control deficiencies including improper PPE use and catheter care, and unsafe, unclean, and poorly maintained environment.
Deficiencies (13)
Failed to treat 5 residents with respect and dignity during in-room meal tray administration; no glasses or straws provided for milk.
Failed to ensure timely physician signature on Florida DNR orders for 3 residents, risking unwanted CPR during emergencies.
Failed to update/revise comprehensive care plan related to pressure injuries for 1 resident; inadequate offloading and repositioning observed.
Failed to ensure accurate assessments for 1 resident with pressure injuries; admission assessments incomplete and wound measurements inconsistent.
Failed to complete PASRR Level II referral for 1 resident with reemergence of serious mental illness, resulting in lack of appropriate psychiatric assessment.
Failed to develop a comprehensive care plan reflective of resident's choice of code status for 1 resident.
Failed to ensure 1 resident received activities designed to meet interests and psychosocial well-being; lack of engagement and documentation.
Failed to ensure physician notification and proper training for resident's spouse administering medications; no physician order or assessment of spouse's capability.
Failed to assist 1 resident in obtaining vision care and failed to ensure glasses were in good repair; broken glasses not repaired or replaced.
Failed to provide appropriate pressure ulcer care and prevention for 1 resident; inadequate offloading, repositioning, and wound management observed.
Failed to implement effective infection prevention and control program for 5 residents; improper PPE use, unclean catheter care, and inconsistent dressing changes noted.
Failed to provide enough food/fluids to maintain health for 1 resident; therapeutic diet not consistently provided and resident reported hunger.
Failed to maintain a safe, clean, comfortable, and home-like environment; cracked walls, broken blinds, missing closet doors, unclean dining cabinets, and other maintenance issues observed.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Interviewed about lack of glasses for milk during meal service |
| Staff G | Registered Nurse | Documented resident's DNR status and care plan meeting |
| Staff I | Unit Manager RN | Interviewed about DNR care plan and wound assessments |
| Staff U | Director of Therapy | Assisted resident with mechanical lift and discussed offloading cushion use |
| Staff W | Physical Therapy | Discussed offloading support for wounds |
| Staff X | Occupational Therapy | Interviewed about offloading cushion sufficiency |
| Staff Y | Occupational Therapy | Interviewed about offloading cushion sufficiency |
| Staff Z | Certified Nursing Assistant | Interviewed about repositioning on offloading cushion |
| Staff AA | Certified Nursing Assistant | Interviewed about repositioning on offloading cushion |
| Staff M | Registered Nurse Unit Manager | Performed wound assessments and discussed wound care |
| Staff Q | Registered Nurse Supervisor | Wound care observation and assessment |
| Staff I | Registered Nurse Unit Manager | Wound assessments and interviews |
| Staff H | Licensed Practical Nurse | Interviewed about resident medication administration and activity engagement |
| Staff C | Licensed Practical Nurse | Observed medication administration and discussed spouse administering medications |
| Staff E | Certified Nursing Assistant | Reported broken glasses and vision care issues |
| Staff J | Dietician | Interviewed about resident nutrition and diet |
| Staff K | Kitchen Manager | Interviewed about meal preparation and resident nutrition |
| Staff Q | Registered Nurse Unit Manager | Interviewed about infection control and PPE use |
| Staff R | Certified Nursing Assistant | Observed providing catheter care without gown |
| Staff S | Certified Nursing Assistant | Observed providing catheter care without gown |
| Staff A | Certified Nursing Assistant | Observed not donning gown while assisting resident on EBP |
| Staff D | Licensed Practical Nurse | Interviewed about PPE availability and compliance |
| Staff C | Infection Preventionist | Discussed infection control program and PPE training |
| Administrator | Acknowledged facility environment deficiencies during walkthrough | |
| Director of Housekeeping | Interviewed about cleaning schedule and cabinet conditions | |
| Regional Plant Manager | Confirmed building repair needs during rounds | |
| Regional Nurse Consultant | Spoke with maintenance about broken blinds and closet doors | |
| Assistant Director of Nursing | Interviewed about broken blinds and bed extender requests |
Inspection Report
Routine
Deficiencies: 18
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to assess the safety, cleanliness, comfort, and home-like environment of the nursing home, specifically focusing on the memory care unit.
Findings
The facility failed to maintain a safe, clean, and comfortable environment, with multiple deficiencies observed including cracked walls, missing or broken closet doors, broken window blinds, peeling cove base, damaged floors, unsanitary dining room cabinets, and maintenance issues such as missing doorknobs and soiled privacy curtains. Staff and administration acknowledged these issues and noted ongoing maintenance and pest control concerns.
Deficiencies (18)
Cracked walls with exposed plaster above air conditioning units, walls and corners including multiple rooms, dining room, and main hallway.
Missing/broken closet doors in multiple rooms.
Foam sprayed in the bottom corner of the window near the back exit door.
Chair/bed rail missing off wall in a room.
Broken window blinds in multiple rooms.
Peeling cove base in common hallway, dining room, and rooms.
Floors of the common hallway cracked, stained, and missing pieces.
Tile missing from bathroom wall with exposed plaster in a room.
Sink in a room separated from the wall and wiggled when touched.
Dining room cabinets with ground-in dirt, half-eaten food, debris, and unsanitary conditions.
Urinal stored on handrail in shared bathroom not labeled for resident use.
Bathroom door missing doorknob, requiring fingers to open and close.
Privacy curtain separating two beds soiled with brown stains.
Broken blinds on window with several missing blinds in a room.
Chipped and cracked wall corner next to closet with molding pulling away.
Closet door missing on one side in multiple rooms.
Resident's request for a bigger bed was not fulfilled; facility lacks bed extenders.
Bifold door panel broken and removed for 3 months, exposing resident's clothing.
Report Facts
Work order number: 4399
Work order creation date: 120324
Work order completion date: 121924
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping | Director of Housekeeping | Acknowledged responsibility for cleaning dining cabinets and admitted missed cleaning schedule |
| Administrator | Administrator | Acknowledged facility issues and ongoing pest control problems |
| Licensed Practical Nurse Staff C | Licensed Practical Nurse | Reported broken blinds and maintenance concerns |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed broken blinds and notified about resident's bed request |
| Regional Nurse Consultant | Regional Nurse Consultant | Spoke with maintenance regarding broken blinds and missing closet doors |
| Regional Plant Manager | Regional Plant Manager | Confirmed findings of necessary building repairs |
| Director of Nursing | Director of Nursing (DON) | Commented on closet door condition |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nursing competencies and medication administration practices, specifically reviewing medication orders and administration for residents.
Findings
The facility failed to ensure licensed nurses had the appropriate competencies to care for residents' medication needs and failed to administer medications according to prescribers' orders for two residents. Deficiencies included failure to properly enter and verify medication orders, lack of documentation for medication discontinuation, and medication errors involving hydrocortisone and gabapentin.
Deficiencies (2)
Failure to ensure licensed nurses have the specific competencies and skill sets to provide nursing and related services to care for residents' medication needs.
Failure to ensure residents were free from significant medication errors by not administering medications in accordance with prescribers' orders for two residents.
Report Facts
Residents reviewed for medication orders: 3
Residents affected: 2
Hydrocortisone dose: 20
Gabapentin dose: 100
Gabapentin dose corrected: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) Unit Manager | Entered hospital orders for Resident #1 and discontinued daily hydrocortisone order |
| Staff B | RN Weekend Supervisor | Did second check on Resident #2's medication order but did not identify the mistake |
| Staff C | RN Unit Manager | Found and adjusted the medication order mistake for Resident #2 but did not notify DON |
| Director of Nursing (DON) | Director of Nursing | Provided information on medication order process and acknowledged deficiencies |
| ARNP | Advanced Registered Nurse Practitioner | Ordered one-time dose of hydrocortisone and was unaware of hospital daily steroid order |
| Administrator | Administrator | Reviewed Resident #1's case and planned education for licensed staff |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident #1 who fell from a full body mechanical lift during transfer on 1/22/24.
Complaint Details
The complaint investigation was triggered by a fall incident on 1/22/24 where Resident #1 fell from a full body mechanical lift that had a missing motor causing the legs of the base to not lock. Resident #1 sustained injuries requiring hospital transfer. The investigation found failures in lift maintenance, staff training, and safe transfer practices.
Findings
The facility failed to protect residents from neglect by not ensuring mechanical lifts were in safe operating condition, staff did not follow safety protocols during transfers, and staff responsible for lift maintenance lacked knowledge and competency. Resident #1 fell from a broken lift, sustaining injuries requiring hospital transfer. The facility used three different brands of mechanical lifts and had issues with sling sizing and lift maintenance.
Deficiencies (5)
Failure to protect residents from neglect by not ensuring full body mechanical lifts were in safe operating condition and staff did not follow safety protocols during transfers.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents related to mechanical lift use.
Failure to ensure nurses and nurse aides have appropriate competencies to safely use mechanical lifts for resident transfers.
Failure to administer the facility in a manner that uses resources effectively to ensure staff competency in inspecting, identifying, and removing unsafe resident equipment and safe transfer techniques with mechanical lifts.
Failure to keep all essential equipment working safely, including mechanical lifts with missing locking motors and lack of proper maintenance and inspection.
Report Facts
Facility census: 113
Residents transferred with mechanical lifts: 19
Residents with incorrect sling size: 13
Staff education completion percentage: 77
Staff education completion percentage: 93
Staff education completion percentage: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Staff A | Certified Nursing Assistant | Involved in transfer of Resident #1 during fall incident; provided statements and interviews about lift use and sling sizing |
| CNA Staff B | Certified Nursing Assistant | Operated mechanical lift during Resident #1 fall; provided statements and interviews about lift use and sling sizing |
| CNA Staff C | Certified Nursing Assistant | Assisted in transfer of Resident #1 during fall incident; provided statements and interviews about lift use and sling sizing |
| RN Staff K | Registered Nurse | Present during Resident #1 fall; provided statements and interviews about lift use and training |
| Maintenance Director | Maintenance Director | Responsible for lift maintenance; lacked training and knowledge about medical equipment; inspected lift with missing motor |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy; responsible for facility oversight and staff hiring |
| Director of Nursing | Director of Nursing | Responsible for nursing services oversight; verified lift was broken; responsible for staff supervision and education |
| Assistant Director of Nursing | Assistant Director of Nursing | Participated in reenactment of transfer incident; confirmed lack of documentation of post-fall education |
| Unit Manager RN Staff J | Unit Manager Registered Nurse | Provided witness statement regarding Resident #1 fall and lift tipping |
| CNA Staff H | Certified Nursing Assistant | Observed transferring Resident #20 with mechanical lift without opening legs of base |
| CNA Staff I | Certified Nursing Assistant | Observed transferring Resident #20 with mechanical lift without opening legs of base |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, infection control, medication management, staffing, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, inadequate grievance documentation, unsafe and unsanitary environment conditions, insufficient assistance with activities of daily living, lack of meaningful activities for dementia residents, inadequate supervision to prevent falls, failure to monitor resident weights, incomplete nurse aide competency reviews, failure to post nurse staffing information daily, improper medication storage and labeling, failure to accommodate food allergies, ineffective pest control, and lapses in infection prevention practices.
Deficiencies (13)
Failed to provide care in a dignified manner by dressing a resident in a hospital gown instead of regular clothes, causing embarrassment.
Failed to document, investigate, and communicate resolution of a grievance voiced by a resident's spouse.
Failed to maintain a safe, clean, comfortable, and homelike environment including unresolved maintenance issues and pest infestation.
Failed to provide necessary care and services to maintain personal hygiene for residents requiring assistance.
Failed to implement meaningful activity programs for residents with dementia on the Memory Care Unit.
Failed to provide appropriate supervision to prevent falls for a resident requiring two-person assist.
Failed to ensure competency and performance reviews are completed every 12 months for nursing staff.
Failed to post nurse staffing information daily as required by regulation.
Failed to secure medications in locked storage and failed to label medications properly.
Failed to accommodate resident food allergies and intolerances, specifically gluten intolerance.
Failed to store, prepare, and serve food in accordance with professional standards, including improper food storage and dish machine temperature monitoring.
Failed to ensure all staff followed infection prevention measures to prevent spread of C. difficile among residents on contact precautions.
Failed to maintain an effective pest control program and failed to provide a sanitary environment free from pests.
Report Facts
Residents reviewed for dignity: 2
Residents reviewed for grievances: 4
Residents reviewed for activities of daily living: 3
Residents reviewed for falls: 4
Residents reviewed for weight monitoring: 6
Staff sampled for competency review: 6
Days with missing nurse staffing postings: 15
Residents reviewed for medication storage: 2
Residents reviewed for food allergy accommodation: 1
Residents reviewed for infection prevention: 3
Residents affected by pest infestation: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Therapy Staff | Mentioned in dignity care deficiency regarding resident in hospital gown |
| Staff O | Certified Nursing Assistant | Mentioned in dignity care deficiency for not offering spare clothes |
| Staff W | Licensed Practical Nurse | Mentioned in dignity care deficiency and weight monitoring interview |
| Staff N | Certified Nursing Assistant | Mentioned in dignity care deficiency and infection control observations |
| Social Services Director | Interviewed regarding grievance process and dignity care | |
| Director of Nursing | Interviewed regarding dignity care, weight monitoring, staffing postings, infection control | |
| Maintenance Director | Interviewed regarding facility maintenance and pest control | |
| CNA Staff C | Certified Nursing Assistant | Mentioned in activities and infection control deficiencies |
| Activity Director | Interviewed regarding activity program deficiencies | |
| Staff T | Certified Nursing Assistant | Mentioned in fall supervision deficiency |
| Staff EE | Certified Nursing Assistant | Mentioned in fall supervision and weight monitoring deficiencies |
| Staff B | Certified Nursing Assistant | Mentioned in competency/performance review deficiency |
| Staff BB | Certified Nursing Assistant | Mentioned in competency/performance review deficiency |
| Dietary Aide Staff R | Mentioned in food service safety deficiency | |
| Certified Dietary Manager | Interviewed regarding food service safety and food allergy accommodation | |
| Registered Dietitian | Interviewed regarding weight monitoring and food allergy accommodation | |
| Assistant Director of Nursing | Interviewed regarding infection prevention and antibiotic stewardship |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 8, 2021
Visit Reason
The inspection was conducted due to complaints regarding grievances, staff treatment, and care concerns for multiple residents, including issues with grievance documentation, abuse prevention, activity provision, respiratory care, and pharmaceutical services.
Complaint Details
The complaint investigation focused on grievances voiced by residents about staff treatment, delays in call light response, verbal abuse, neglect, lack of activities, improper oxygen therapy, and medication management issues. The investigation found substantiated issues with grievance documentation, abuse prevention, activity provision, respiratory care, and pharmaceutical services.
Findings
The facility failed to document and investigate resident grievances properly, did not implement abuse prevention policies effectively, lacked meaningful activity programs for residents with cognitive impairments, failed to provide oxygen therapy according to physician orders for some residents, and had unsecured medication carts and issues with controlled substance management.
Deficiencies (5)
Failed to document description of grievances, investigation, and prompt interventions for 4 residents who voiced grievances.
Failed to implement abuse prevention policies and procedures and document thorough investigation of resident complaints of staff treatment for 4 residents.
Failed to provide meaningful and empowerment activity programs to meet assessed needs of 8 residents with emotional and psychological needs.
Failed to provide oxygen therapy in accordance with physician orders for 2 residents, including malfunctioning oxygen concentrator and improper oxygen delivery.
Failed to ensure timely access to locked emergency-controlled substance medications, failed to audit and reconcile disposition of discharged controlled substances, and failed to ensure secured and locked medication carts.
Report Facts
Disciplinary actions: 3
Disciplinary actions: 7
Oxygen liters per minute: 2
Oxygen liters per minute: 3
Oxygen liters per minute: 2.5
Controlled substance medication issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Risk Manager | Mentioned in relation to grievance investigation and reporting |
| Staff O | Certified Nursing Assistant | Named in multiple disciplinary actions and resident complaints about poor customer service |
| Staff Q | Certified Nursing Assistant | Named in multiple disciplinary actions and resident complaints about poor customer service |
| Staff R | Certified Nursing Assistant | Involved in resident interaction with behavioral issues |
| Staff I | Unit Manager | Interviewed regarding resident behavior and grievance follow-up |
| Staff A | Certified Nursing Assistant | Interviewed regarding oxygen therapy management for Resident #24 |
| Staff B | Licensed Practical Nurse | Observed malfunctioning oxygen concentrator and replaced it for Resident #24 |
| Staff C | Unit Manager Registered Nurse | Confirmed oxygen concentrator settings for Resident #60 and medication cart security |
| Staff E | Certified Nursing Assistant | Interviewed about activity provision on Memory Care Unit |
| Staff G | Certified Nursing Assistant | Observed not interacting with residents during activity time |
| Staff H | Licensed Practical Nurse | Attempted to open locked medication box |
| Staff J | Registered Nurse | Attempted to open locked medication box and returned with key |
| Staff K | Licensed Practical Nurse | Attempted to open locked medication box |
| Staff L | Licensed Practical Nurse | Reported maintenance changed medication box lock |
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