Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Care Center during CMS and state inspections, most recent first.
Surveyors found multiple rooms with environmental deficiencies such as missing paint, oxidized bed frames, broken side rails, detached baseboards, and unfinished repairs. These issues were not reported through the facility's work order system, and the maintenance director was unaware of them prior to the inspection. The facility's process for identifying and addressing environmental concerns was not effectively followed, resulting in a failure to provide a safe, clean, and homelike environment for residents.
Two residents with diabetes were admitted without timely physician orders for insulin or blood glucose monitoring, despite hospital discharge instructions indicating ongoing insulin therapy. Facility staff did not reconcile hospital medication lists with a provider upon admission, resulting in delayed insulin administration and blood glucose checks. Staff interviews revealed confusion over discharge paperwork and inconsistent use of admission protocols.
Two residents with diabetes did not receive their prescribed insulin upon admission due to incomplete medication reconciliation and lack of provider review. Nursing staff relied on confusing hospital discharge paperwork and did not consistently verify medication needs with a provider, resulting in delayed insulin administration and elevated blood glucose levels.
A resident with multiple medical conditions and a high risk for falls developed significant bruising that was not promptly identified, investigated, or reported by staff. Despite protocols for skin checks and incident reporting, staff failed to document or communicate the presence of new bruises, and nursing administration was unaware of the injury until it was pointed out during a survey. This resulted in a deficiency for not investigating and reporting suspected abuse, neglect, or injuries of unknown origin as required by facility policy.
A resident with complex medical conditions, including bladder dysfunction and chronic kidney disease, was not provided a urology consult after a failed voiding trial, despite verbal orders from the ARNP. Miscommunication between the ARNP, DON, and nursing staff, along with the absence of a facility policy on care consultation and referral, led to the omission of the required specialist evaluation.
The facility failed to update PASRR Level II evaluations for several residents with new mental health diagnoses. Despite having conditions like schizoaffective disorder and dementia, the necessary evaluations were not completed, as required by regulations. The Social Services Director acknowledged the oversight, which affected the care planning and assessment process.
The facility failed to complete the PASRR for three residents with mental disorders or intellectual disabilities. A resident with major depressive disorder and Alzheimer's disease had a blank PASRR, another with multiple mental health diagnoses had no indication of mental illness on their PASRR, and a third resident's PASRR only marked schizophrenia, omitting other diagnoses. The Social Services Director acknowledged the PASRRs were not updated upon acquiring new diagnoses, contrary to facility policy.
The facility failed to maintain resident rooms in a safe and sanitary manner in Zones 3, 6, and 8. Observations included stained and damaged walls, dirty toilets, and unclean bed frames. A resident expressed dissatisfaction with her room's condition. The Regional EVS Director acknowledged cleaning lapses, and the Director of Maintenance noted that repairs were delayed and not documented in the work orders system.
A resident with severe cognitive impairment was discharged without receiving a 30-day advance notice, as required by the facility's policy. The notice was given on the day of discharge, lacking documentation of prior notification to the resident or their emergency contact. The discharge was facility-initiated due to capacity issues and behavioral incidents, but there was no evidence of attempts to meet the resident's needs or justification for the transfer.
The facility failed to accurately code the MDS Assessments for two residents with Serious Mental Illness, as indicated by their PASRR Level II Determination Summary Reports. Despite having diagnoses such as major depressive disorder and generalized anxiety disorder, the MDS Assessments inaccurately reflected no serious mental illness. The MDS Coordinator and DON confirmed the inaccuracies and noted the absence of a specific policy for MDS completion.
A resident with chronic edema and DVT was not consistently monitored or documented, leading to a deficiency in care. Despite the presence of edema, the care plan was not updated in a timely manner, and staff interviews revealed a lack of consistent documentation. Facility policies on documentation and monitoring were not followed, resulting in inadequate care for the resident.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified multiple environmental deficiencies in fourteen resident rooms during a facility tour, including missing paint on walls, oxidized and stained bed frames, broken side rails, detached edging on bedside tables, holes in walls, missing or detached baseboards, unfinished work under sinks, toilets lacking sealant, and inappropriate storage of toilet paper. Additional concerns included air mattress cords improperly placed and plugged into televisions, and black marks or missing boards from walls. These issues were directly observed and documented by surveyors during their inspection. Interviews with the Director of Maintenance (DOM) and the Nursing Home Administrator (NHA) revealed that these environmental concerns had not been reported through the facility's work order system, and the DOM was unaware of the issues prior to the survey. The NHA stated that department heads are expected to identify and report such concerns during daily rounds, and that staff are trained to report environmental issues. However, the specific deficiencies observed by surveyors had not been communicated or addressed through the established reporting and maintenance processes, resulting in the failure to maintain a safe, clean, and homelike environment as outlined in the facility's policy.
Failure to Obtain and Implement Physician Orders for Immediate Care Upon Admission
Penalty
Summary
The facility failed to ensure that two residents received physician orders for their immediate care and necessary services upon admission. Both residents were admitted with a history of diabetes mellitus and required insulin therapy, as indicated by their hospital discharge documentation and medication reconciliation. However, upon admission, there was no documentation that the facility staff reviewed or reconciled the discharge medication list with a provider, nor were appropriate insulin orders entered in a timely manner. In both cases, the residents did not receive their prescribed insulin until several days after admission, and blood glucose monitoring was also delayed. For the first resident, the hospital discharge records indicated ongoing insulin therapy, but the facility did not initiate insulin orders or blood glucose checks upon admission. The resident and their representative reported concerns to the nursing staff about the lack of insulin administration, and a grievance was filed. The facility's records showed that insulin was not administered until two days after admission, and long-acting insulin was not started until four days after admission. The resident's blood glucose was not checked until two days post-admission, at which point it was elevated. The second resident was also admitted with a diagnosis of diabetes and a hospital discharge summary indicating insulin therapy. However, the facility did not enter insulin orders or perform blood glucose checks until two days after admission. The resident's representative informed the admitting nurse about the need for insulin, but the orders were not entered, and the first blood glucose check revealed a significantly elevated level. Interviews with staff revealed confusion regarding the hospital discharge paperwork and a lack of communication with the provider to verify or clarify medication orders. The facility lacked a policy on medication reconciliation or diabetes management, and staff did not consistently follow the admission checklist to ensure proper medication review and provider notification.
Failure to Administer Prescribed Insulin Upon Admission Due to Inadequate Medication Reconciliation
Penalty
Summary
Two residents were admitted to the facility and did not receive their necessary prescribed insulin medications upon admission. In the first case, the resident and their representative reported concerns that insulin was not administered as ordered, with the resident only receiving half of the normal dose after repeated requests. The resident's hospital discharge paperwork included orders to stop insulin, which led the admitting nurse to withhold the medication despite the resident's statements and a filed grievance. There was no documentation that the discharge medication list was reviewed or reconciled with a provider upon admission, and blood glucose monitoring was not initiated until two days after admission, at which point the resident's blood glucose was elevated. In the second case, another resident with a history of diabetes was admitted without clear documentation of insulin orders in the hospital paperwork, though the discharge summary indicated the resident was on insulin. The resident's representative informed the admitting nurse of the need for insulin, but the resident went a day or more without receiving it. Blood glucose checks were not performed until two days after admission, revealing significantly elevated levels. Insulin orders were not entered until two days post-admission, and there was no evidence that the medication reconciliation was reviewed with a provider at the time of admission. Interviews with nursing staff and facility leadership revealed inconsistent practices regarding medication reconciliation and provider notification upon admission. The Director of Nursing confirmed that there was no documentation of provider review for the admission medications and acknowledged that nurses were expected to call the provider before entering orders. The facility lacked policies on medication reconciliation, diabetes management, or a standardized admission process, and the use of the admission checklist was inconsistent among staff. These actions and inactions resulted in residents not receiving necessary prescribed medications in a timely manner.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who had multiple medical conditions, including osteoarthritis, epilepsy, and anemia, and was at high risk for falls and skin impairment. Documentation showed that the resident had a fall, after which darker bruises were observed on her upper thighs, described as appearing to be from prior falls. However, subsequent skin checks and daily skilled notes did not document any new or existing bruises, and staff interviews revealed inconsistent awareness and reporting of the bruising. The resident was also noted to have additional bruising and skin tears on her forearm, which she attributed to a bracelet, and a significant bruise on her upper left hip that had been present for 10-14 days, but this was not documented or reported to nursing administration until brought to their attention during the survey. Interviews with staff, including LPNs and CNAs, indicated that while there were protocols for assessing and documenting falls and skin changes, these were not consistently followed. Staff were unaware of recent falls or new bruising, and weekly skin checks were not reliably performed or documented. The DON and RNC confirmed that the expected weekly skin sweeps were not being completed, and the nursing administration team was unaware of the new bruising on the resident's hip until it was pointed out during the survey. The facility's own policies required prompt notification and investigation of injuries of unknown source, as well as thorough documentation and communication with physicians and resident representatives, but these procedures were not followed in this case. The lack of timely investigation and reporting of the resident's bruising, as well as the failure to perform and document regular skin checks, resulted in a deficiency related to the facility's responsibility to identify, investigate, and report suspected abuse, neglect, or injuries of unknown origin. The facility's policies on change in condition and abuse prevention were not adhered to, leading to a delay in recognizing and addressing potential harm to the resident.
Failure to Provide Urology Consultation Following Failed Voiding Trial
Penalty
Summary
A deficiency occurred when the facility failed to ensure a urology consultation was provided for a resident with multiple complex diagnoses, including Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of the bladder, infection and inflammatory reaction due to an indwelling urethral catheter, and chronic kidney disease. Upon admission, there was a verbal order to consult urology for urinary retention, and the ARNP documented in progress notes that a voiding trial should be initiated, with instructions to consult urology if the trial failed. Despite these instructions, the voiding trial was either not performed as ordered or, when eventually conducted and failed, the required urology consult was not arranged. Interviews with facility staff revealed miscommunication and lack of follow-through regarding the urology consult order. The DON acknowledged that the ARNP had requested a voiding trial and a urology consult if the trial failed, but stated that the ARNP did not enter the consult order into the system. The ARNP, however, reported that she verbally instructed both the DON and the Unit Manager on multiple occasions to consult urology after the failed voiding trial. The facility did not have a policy or procedure in place regarding care consultation and referral, contributing to the failure to secure the necessary specialist evaluation for the resident.
Failure to Update PASRR Level II Evaluations for Residents with New Diagnoses
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Review (PASRR) Level II evaluations for residents with new qualifying mental health diagnoses. This deficiency was identified for five residents out of ten sampled. The PASRR Level II evaluations were not updated to reflect new diagnoses, which is a requirement under state and federal regulations. The facility's policy mandates that all residents receive a PASRR evaluation, and any significant changes in a resident's mental health status should prompt a Level II review. Resident #1 had multiple mental health diagnoses, including schizoaffective disorder and unspecified dementia, but the PASRR Level II was not updated to include these new diagnoses. Similarly, Resident #3 and Resident #98 had diagnoses of generalized anxiety disorder and unspecified dementia, yet their PASRR Level I evaluations incorrectly indicated that a Level II evaluation was not required. Resident #46 and Resident #38, both with serious mental illness, also lacked updated PASRR Level II evaluations after acquiring new diagnoses. The Social Services Director acknowledged that the PASRRs were not updated upon acquiring new diagnoses and that Level II PASRRs should have been completed. The facility's policy emphasizes the importance of incorporating PASRR recommendations into resident assessments and care planning, but this was not adhered to in these cases. The failure to update PASRR evaluations upon significant changes in residents' mental health status led to the identified deficiency.
Failure to Complete PASRR for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Reviews (PASRR) for three residents with mental disorders or intellectual disabilities. Resident #36 was admitted with newly acquired diagnoses of major depressive disorder and Alzheimer's disease, but their Level I PASRR was left blank, and the qualifying diagnoses were not checked. Resident #102 was admitted with multiple mental health diagnoses, including bipolar disorder and major depressive disorder, yet their PASRR Level I Screen did not indicate any mental illness. Resident #53 was admitted with major depressive disorder and generalized anxiety disorder, but their PASRR Level I Screen only marked schizophrenia, leaving out the other diagnoses. The Social Services Director (SSD) acknowledged that the PASRRs were not updated upon acquiring new diagnoses. The facility's policy requires coordination with the PASRR program to incorporate recommendations into a resident's assessment and care planning. However, the policy was not followed, as evidenced by the lack of updated PASRRs for residents with newly identified mental health conditions. The SSD stated that after admission, she reviews the resident's PASRR and diagnoses with the nursing leadership team to determine if a Level II PASRR evaluation is required, but this process was not effectively implemented in these cases.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a safe, sanitary, and homelike manner in three zones, specifically Zones 3, 6, and 8. During a tour of Zone 6/8, several issues were observed, including stained and damaged walls, dirty and uncaulked toilets, and unclean bed frames. A resident expressed dissatisfaction with the condition of her room, noting a large stain on the ceiling and a crumbling wall behind her bed. The Regional Environmental Services (EVS) Director acknowledged that the rooms should have been cleaned, especially during terminal cleaning, and noted that the deep cleaning schedule was not followed as room [ROOM NUMBER] had not been deep cleaned since October. In Zone 3, environmental concerns were identified in multiple rooms, including holes, chipped paint, and damaged baseboards. The toilet base caulking in one room was stained with a brown substance. Staff F from housekeeping stated that he would report uncleanable or damaged items to maintenance, but the Director of Maintenance (DOM) confirmed that the rooms with concerns were not documented in the work orders management system. The DOM was aware of the damaged walls and baseboards and mentioned that repairs were scheduled but delayed due to the facility's census. The facility's maintenance policy, revised in December 2009, outlines the responsibilities of the maintenance department to keep the building in good repair and free from hazards. However, the observations and interviews indicate that the policy was not effectively implemented, as evidenced by the lack of documentation in the work orders system and the failure to address the identified environmental concerns in a timely manner.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and/or Discharge Notice to a resident, identified as Resident #94, who was part of a group of three residents reviewed for the transfer/discharge process. The deficiency was identified when it was found that Resident #94 did not receive a 30-day advance notice of discharge, as required by the facility's policy. The notice was only given on the day of discharge, and there was no documentation indicating that the resident or their emergency contact had been informed in advance. Additionally, the notice lacked the name or signature of the person receiving it. Resident #94, who was admitted to the facility with severe cognitive impairment and diagnosed with dementia, was involved in incidents that led to the decision for discharge. The resident's medical records indicated a history of impaired cognition, memory, and judgment, with a BIMS score of 6/15 and a SLUM exam score of 10/30. Despite these cognitive deficits, the facility did not document any attempts to meet the resident's needs or provide evidence of the services available at the new facility that were not available at the current one. Interviews with facility staff, including the Psychiatric Physician Assistant and the Director of Nursing, revealed that the discharge was facility-initiated due to capacity issues and behavioral incidents involving Resident #94. The resident's emergency contact was not notified of the transfer, and there was no evidence of a 30-day discharge notification. The facility's policy requires that residents and their representatives receive written notice at least 30 days prior to a transfer or discharge, except in specific circumstances, none of which were documented in this case.
Inaccurate MDS Coding for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) Assessment was accurately coded for two residents, leading to a deficiency in the accuracy of assessments. Resident #46 was admitted with diagnoses including adjustment disorder with depressed mood, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Despite a Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report indicating that Resident #46 met the definition of Serious Mental Illness, the MDS Assessment inaccurately reflected that the resident did not have a serious mental illness or related condition. Similarly, Resident #38, who was admitted with diagnoses such as major depressive disorder, generalized anxiety disorder, and dementia, also had a PASRR Level II Determination Summary Report confirming a Serious Mental Illness. However, the MDS Assessment for Resident #38 was inaccurately coded, indicating no serious mental illness or related condition. Interviews with the MDS Coordinator and the Director of Nursing revealed that the facility lacked a specific policy and procedure for MDS Assessment completion, relying solely on regulations, which contributed to the inaccuracies in the assessments.
Inadequate Monitoring and Documentation of Chronic Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with chronic edema, as evidenced by inconsistent monitoring and documentation of the resident's condition. The resident, who was observed with swelling in both lower legs, had a diagnosis of deep vein thrombosis (DVT) confirmed by an ultrasound. Despite the presence of edema, the facility's records did not consistently reflect this condition, and the care plan was not updated in a timely manner to address the resident's needs. Interviews with staff revealed a lack of consistent documentation and monitoring of the resident's edema. The Director of Nursing (DON) and other nursing staff acknowledged that the resident's condition was not adequately documented, and there was a failure to establish a baseline for monitoring the edema. The resident's care plan was only revised after the deficiency was identified, indicating a delay in recognizing and addressing the resident's chronic condition. The facility's policies on charting and documentation, as well as changes in a resident's condition, were not followed. The policies required documentation of changes in the resident's condition and progress toward care plan goals, but these were not consistently adhered to. The lack of documentation and monitoring led to a deficiency in providing care according to professional standards and the resident's needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 343 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clearwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbourwood Post-acute And Rehabilitation Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Kensington Gardens Rehab And Nursing Center | 1.7 mi | ★★★★★ | 12 | 0 |
| Regency Oaks Health Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Sand Key | 2.3 mi | ★★★★★ | 0 | 0 |
| Aviata At The Harbor | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.