Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avante At Ocala, Inc during CMS and state inspections, most recent first.
Failure to Maintain Resident Fingernail Grooming: A resident with contractures and a hx of TBI was observed in bed with very long, dirty fingernails, with the nails on one hand extending about 1/2 to 3/4 inch past the fingertips. The resident said they wanted the nails cut and clean and did not remember when they were last done. Staff interviews showed the CNA and RN were aware the nails were long, but the grooming need had not been addressed.
Delayed wound care orders for a pressure ulcer. A resident admitted with multiple fractures had a sacral pressure ulcer and a skin tear documented on the admission assessment, but wound care orders were not obtained right away. The sacral wound later required multiple dressing orders, and the wound consult identified it as an unhealed Stage 3 PI. The DON stated staff did not obtain a wound care order when the pressure ulcer was identified on admission.
The facility failed to ensure the person directing dietary services met required qualifications. The Dietary Manager’s file lacked documentation of the needed certification or education, and the Corporate Dietary Manager stated the Dietary Manager did not have the required qualifications. The facility policy required the director of food and nutrition services to hold a qualifying certification or degree.
Failure to implement performance improvement plans and infection control deficiencies. The facility identified problems with PASRR, medication administration and storage, wound care, and infection control, but the related PI documentation lacked required education, competencies, and audits. Staff were also observed with staffing mismatches, delayed resident supervision, missed or delayed care, poor hand hygiene, improper enteral tube syringe handling, an open soiled linen room door, and a CNA entering a resident’s contact isolation room without a gown.
The facility did not fully implement PIPs for medication administration, wound management, infection control, and PASRR. Documentation showed some LPN medication observations, but it lacked evidence of 5 rights education, weekly med cart audits, and the full observation schedule. The wound care PIP lacked documented staff education, and the infection control PIP lacked the required audits and did not document PPE or transmission-based precautions education. No PIP documentation was provided for PASRR.
The facility failed to maintain a homelike environment when multiple residents did not have accessible bedside light cords in rooms across several hallways. In another room, a resident’s blinds were broken, the phone had no dial tone with a missing wall plate cover and exposed wiring, and a separate room had damaged wallboard and a detached baseboard with an electrical cord running through the area. The DON/plant ops leadership confirmed the issues and noted the light cords were not accessible.
Inaccurate PASRR screening was identified for multiple residents when records showed depression, anxiety, and related psychiatric diagnoses that were not reflected on the PASRR forms. One resident had a PASRR that did not document MI despite physician orders for trazodone for depression and a psychiatry note describing depressive episodes lasting more than 2 weeks. Two other residents had psychiatry notes documenting MDD, depression, and anxiety, yet their PASRRs did not include the mental illness findings.
Insufficient nursing staffing and inaccurate assignment tracking led to unmet resident needs and delayed care. During observation, staffing boards did not match actual staff present, a call light was ringing, and two residents ordered for 1:1 supervision were not consistently covered as assigned. Staff reported repeated call-offs, no night supervisor, inability to reach on-call support, excessive resident assignments, and delayed responses to call lights, incontinence care, and medications. Residents also reported long waits for assistance and missed or delayed meds.
Unsanitary kitchen conditions were observed, including food debris and residue under prep tables, grease and dried food splatter on walls and ceiling, holes and missing floor tiles, and food debris near doorways. Surveyors also observed a live roach on the wall and multiple live roaches near the dishwashing area, and the Regional Dietary Manager stated the kitchen was unsanitary and not in accordance with corporate standards.
Failure to complete and transmit a discharge MDS assessment for a resident who was discharged. The LPN MDS Coordinator stated the discharge assessment was never done, and the resident’s MDS did not show a discharge assessment. Facility policy requires discharge assessments to be completed per CMS and RAI MDS 3.0 guidelines.
MDS assessments were inaccurate for three residents. One resident with no teeth was coded as having natural teeth, another resident with TIA, bilateral foot drop, and left hemiparesis was not coded correctly for lower extremity ROM impairment or neurological diagnoses, and a third resident who was transferred to another SNF was coded as discharged to home/community instead of SNF. Staff later acknowledged the coding errors.
Failure to develop comprehensive, person-centered care plans for three residents. One resident was on hospice, but the care plan did not reflect hospice services despite hospice election paperwork and staff acknowledgment that the plan had not been updated. Another resident had limited expressive communication and multiple neurologic diagnoses, yet the care plan did not address the communication deficit. A third resident was self-administering supplements, but the care plan did not include focus, goals, or interventions for safe medication self-administration.
Failure to Provide Nail Care Assistance: A resident who was dependent on staff for personal hygiene had fingernails that were observed to be excessively long, with the nails extending into the palm of a contracted hand. The resident’s representative reported that the nails were not being cut and had been digging into the palm, and a CNA later stated the nails were too long and should have been cut during the prior bath.
The facility failed to ensure the right dosage was documented before administering Voltaren gel to a resident, and failed to ensure a separate resident had a documented order and record support for a right forearm dressing. The DON stated the Voltaren order did not include a dosage, and the Unit Coordinator said she was unsure why the dated dressing was present because there should have been a physician order and supporting documentation.
Improper Storage of Respiratory Delivery Devices: Staff failed to store respiratory delivery devices properly for two residents. One resident with acute respiratory failure and pneumonia had a nebulizer mask left open to air on the bedside table after breathing treatments, and another resident with COPD had an oxygen mask left on top of the bed. Staff stated the masks should be placed in a bag or covered when not in use, and the facility policy required delivery devices to be covered.
Medication Error Rate Exceeded Allowed Threshold: An LPN prepared a chewable aspirin for a resident whose order was for delayed-release aspirin, and another LPN incorrectly planned to hold Midodrine based on a BP reading even though the order required holding only if SBP was greater than 130. The facility’s medication error rate was 5.41%, exceeding the allowed 5% threshold.
Unsecured, expired, and unattended medications were observed in resident rooms and on medication carts. An LPN and the DON acknowledged that medications were left at the bedside unsecured, a resident’s lockbox contained expired items and was not locked, glucometer strip containers were undated, and an LPN left one resident’s pre-poured medication cup unattended on top of the cart while administering care to another resident.
Incomplete and untimely MAR documentation: Multiple residents had missing MAR entries for ordered meds, including routine meds, psychotropics, insulin, and supplements. An LPN stated the residents received their meds but she forgot to document them after passing meds and sometimes charted only at the end of the shift. The DON stated meds are expected to be charted after administration, and the facility policy required accurate, complete, timely, dated, timed, and signed documentation.
An LPN failed to perform hand hygiene while administering meds to residents, and also did not rinse an enteral flush syringe after use. The laundry area’s soiled linen barrier was left open, and a CNA cared for a resident with shingles on contact isolation without wearing a gown. The DON stated contact precautions for shingles require gown, mask, and gloves.
The facility did not ensure that a resident with hypokalemia received required quarterly nutritional evaluations by an RD, as outlined in the care plan, and failed to develop a care plan addressing PTSD for another resident, despite clear documentation of ongoing symptoms. These omissions were confirmed by facility staff and were not in accordance with established care planning policies.
The facility did not ensure an adequate supply of clean linens, washcloths, towels, and protective bed pads, resulting in residents and staff frequently running out of these essential items before the end of shifts. Staff reported difficulties in providing care due to the shortages, and observations confirmed limited supplies available on linen carts during the night.
The facility did not ensure snacks were proactively offered and served to residents according to their needs and preferences. Several residents, including one with diabetes and another with seizure disorder, reported that snacks were only available if they went to the nurses' station, which was not possible for all. Staff confirmed snacks were provided only upon request, contrary to facility policy requiring nursing staff to offer snacks to all residents daily.
A resident's medical record lacked complete and accurate documentation for behavior monitoring, as required by physician orders and facility policy. Staff only recorded check marks and initials instead of detailed behavior codes and interventions, and there were inconsistencies in progress notes regarding medication refusal and observed behaviors. Interviews with an LPN and the DON confirmed the documentation was insufficient.
A facility failed to accurately complete a Level I PASRR for a resident with bipolar disorder, documenting a depressive disorder instead. The discrepancy was confirmed by the DON, highlighting a failure in accurately recording the resident's mental health condition.
Two residents received narcotic pain medication outside prescribed parameters. One resident was given Tramadol despite a pain level of zero, and another received Hydrocodone-Acetaminophen for pain levels below the prescribed threshold. Staff interviews confirmed these errors, highlighting a failure to adhere to physician orders and facility policy.
The facility failed to securely store medications, as observed with two residents who had unsecured medications in their rooms. One resident had vitamin C gummies and red grape seed vitamins on their bedside table, while another had Diclofenac Sodium gel on their overbed table. The DON confirmed that medications should be secured and residents assessed for self-administration, with a lockbox provided if approved.
The facility failed to ensure proper food storage and handling, with unlabeled fruits in the cooler, raw ground beef left on the counter, and uncovered cake pans. Staff confirmed these practices did not align with facility policies.
A facility failed to ensure staff used proper PPE during high-contact care for a resident under Enhanced Barrier Precautions. An Infection Prevention Officer was observed applying a wound dressing without a gown, contrary to facility policy and signage requirements. Interviews confirmed the lapse, with the officer acknowledging the oversight and the DON emphasizing the need for gown and glove use during such care.
Failure to Maintain Resident Fingernail Grooming
Penalty
Summary
The facility failed to provide necessary assistance with grooming for one resident who was unable to perform the task independently. During observation on 6/3/2026 at 9:25 AM, the resident was lying in bed with a left-hand contracture and a right hand with very long, dirty fingernails. The fingernails extended about 1/2 inch to 3/4 inch from the fingertips, and the left-hand nails could not be fully observed because of the contracture. The resident stated that they did not like the nails, wanted them cut and clean, and did not remember when their nails were last done. Record review showed the resident was admitted with diagnoses including metabolic encephalopathy, depressed mood, contracture of the left hand and left wrist, and a history of traumatic brain injury. Staff interviews confirmed the nails were long and had not been addressed: a CNA stated the resident was not theirs and did not know the bath schedule, another CNA stated the resident was theirs but they had been too busy to get to them, and an RN stated resident nails are important to hygiene and should be maintained, but had not seen the resident's nails before acknowledging they were long. The DON stated the expectation was for residents' nails to be trimmed and clean each time they were bathed, and the facility policy stated care and services should be person-centered and support each resident's preferences and choices.
Delayed Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that one resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. The resident was admitted with multiple pelvic and sacral fractures, and the nursing admission assessment completed on the day of admission documented a pressure ulcer on the sacrum and a skin tear on the right forearm. However, the resident’s physician orders did not include wound care for either wound until several days later, despite a wound consult being ordered as needed on admission. The record showed that the sacral wound later received multiple wound care orders, including cleansing and various dressings, and a wound care consultation on 3/31/2026 identified the sacral wound as an acute Stage 3 pressure injury that had not healed. The initial wound encounter measurements were 6 cm by 6.5 cm by 1.5 cm. During interview, the DON stated that staff did not obtain a wound care order when the pressure ulcer was identified on admission and that the nurse should have called the doctor to obtain the order, which should have been in place when the wound care physician visit occurred.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure the individual responsible for directing dietary services met the required qualifications. Review of the Dietary Manager’s personnel file did not contain documentation showing the staff member had the required certification or education, and a request was made for proof of certification as a Certified Dietary Manager, Certified Food Service Manager, similar national certification, or an associate’s degree or higher in food service management or dietary management. During an interview, the Corporate Dietary Manager stated the Dietary Manager did not have the required qualifications in accordance with regulatory requirements. Review of the facility’s Food and Nutritional Services policy showed the facility must designate a person to serve as the director of food and nutrition services who meets one of the listed qualification pathways.
Failure to Implement Performance Improvement Plans and Infection Control Deficiencies
Penalty
Summary
The facility administration failed to fully implement performance improvement plans for identified non-compliance related to PASRR, medication storage and administration, wound care, and infection control. The Administrator stated the facility had identified concerns regarding PASRR and initiated a performance improvement project on 1/12/2026, wound management on 2/1/2026, and infection control on 2/13/2026. The DON stated the facility identified problems with medication administration on 1/12/2026 related to correct medication and storage in medication carts, and that plans were also developed for wound management and infection control. However, when the performance improvement documentation was reviewed, the medication administration plan did not include completion of medication administration competencies for licensed nurses, education on the five rights of medication administration, or weekly audits of medication carts. Ten medication administration observations were listed across multiple dates, involving three nurses on different days. The wound management performance improvement documentation dated 2/1/2026 did not include education provided to staff regarding wound care. The infection control performance improvement documentation did not include education on PPE use, hand hygiene, or transmission-based precautions, and there were no audits. When asked for missing documentation to verify implementation of the performance improvement plans, no additional documentation was provided. The President of Regulatory stated that education was not documented accurately, and no other supporting documents were provided. During observations and interviews, additional deficiencies were identified in staffing and infection control practices. On 3/23/2026, the facility had minimal staff presence, a call light was persistently ringing, and staffing boards did not match actual staff present. The South Wing assignment sheet showed one LPN and four CNAs for 53 residents, including two residents ordered for 1:1 supervision, but one CNA listed on the assignment sheet could not be located. Resident #144 was observed without staff present for the ordered 1:1 supervision, and Resident #101 was being supervised 1:1 by a CNA who stated that when assigned to 1:1 she did not assist other residents. Staff and residents described repeated staffing shortages, delayed call light response, delayed incontinence care, and missed or delayed medications. In addition, a LPN was observed failing to perform hand hygiene between residents and before handling medications, another LPN did not rinse and dry a syringe after administering medication via gastrostomy tube, the laundry soiled linen room door was observed propped open, and a CNA entered the room of a resident on contact isolation for shingles without wearing a gown.
Incomplete Implementation of QAPI Performance Improvement Plans
Penalty
Summary
The facility failed to fully implement its performance improvement plans for medication administration, wound management, infection control, and PASRR. During interview, the Administrator stated that the facility had identified concerns with PASRR and had initiated performance improvement projects for wound management/pharmacy recommendations and infection control. However, when documentation was requested to verify implementation, no PIP documentation was provided for PASRR. For the medication administration PIP dated 01/12/2026, the facility documented a focus on completion of medication administration competencies with licensed nurses, weekly medication cart audits for 12 weeks, education on the 5 rights of medication administration, and medication observations. The documentation provided showed ten observations of licensed nursing staff, including six observations of one LPN, three observations of another LPN, and one observation of a third LPN. The record did not include documentation of staff education in the 5 rights or the weekly medication cart audits. For the wound management PIP dated 02/01/2026, the facility stated it would ensure residents had appropriate wound management and treatment, including verification of wound orders, consultation with the wound care NP, and staff education on wound care, with weekly audits of five resident wounds. The documentation provided did not contain evidence of licensed nursing staff education. For the infection control PIP dated 02/13/2026, the facility identified education on hand hygiene, PPE usage, and transmission-based precautions, along with audits several times per week and weekly thereafter. The documentation provided did not contain the weekly audits, and the education documentation reviewed was limited to hand competency education and did not document PPE usage or transmission-based precautions. The Administrator and the President of Regulatory both stated that documentation was missing or not accurately documented, and the facility policy required the QAA committee to review and approve plans of correction.
Accessible Room Fixtures and Room Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure a homelike environment by not providing residents with accessible room lighting controls in multiple hallways. During observation, a light fixture behind one resident’s bed had no cord attached, and the resident stated there was no cord to turn the light on or off. Additional observations on the 100, 200, and 300 hallways found multiple residents’ rooms with light cords missing or not accessible behind the beds. The Director of Plant Operations and the Administrator confirmed the light cords behind residents’ beds were not accessible, and the Director of Plant Operations stated the light cords needed to be fixed. The facility also failed to ensure that a resident’s telephone and window blind mechanisms were in working order, and another resident’s room had damaged wall conditions with an exposed electrical cord. In one resident’s room, the blind draw strings were broken, the blinds could not be raised properly, the phone line cable was hanging out of the wall, the wall plate cover was missing, and there was no dial tone when the phone was plugged in. The resident stated the phone and blinds had been reported before but were not fixed. Work orders showed prior requests for phone and blind repairs, and the Director of Plant Operations stated parts had to be ordered for the phone jack and that blinds were ordered only after multiple replacements were needed. In another resident’s room, the baseboard below the air conditioning unit was detached, the wallboard was damaged and crumbling, and an electrical cord was running through the damaged area; the Director of Plant Operations stated he did not know the baseboard was broken.
Inaccurate PASRR Screening for Mental Illness
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for 3 of 4 residents reviewed, including Residents #2, #11, and #28. Resident #11’s record showed admission with a diagnosis of adjustment disorder with depressed mood, and the Florida AHCA PASARR dated 10/22/2025 did not document any mental illness. However, physician orders dated 10/23/2025 included Trazodone HCL 50 mg at bedtime for depression, and a psychiatry subsequent note dated 12/2/2025 documented that the history suggested episodes of depression lasting more than 2 weeks. During interview, the DON stated the PASARR should have been redone with depression listed in the history. Resident #2’s psychiatry subsequent note dated 12/11/2025 documented depression, anxiety, and dementia, and identified MDD, recurrent, with a history suggesting episodes of depression lasting more than 2 weeks with significant distress and functional impairment. Resident #28’s psychiatry subsequent note dated 11/25/2025 documented depression and anxiety and identified MDD, recurrent, with a similar history of depressive episodes lasting more than 2 weeks. Resident #28’s PASARR dated 3/31/2023 stated the resident did not have any suspected or known MI. During interview, the Regional Nurse Consultant stated the PASRR was incorrect and should have included all of the residents’ mental illness including depression and anxiety. The facility policy stated it coordinates assessments with the PASARR program for individuals with mental disorder, intellectual disability, or related condition.
Insufficient Nursing Staffing and Inaccurate Assignment Tracking
Penalty
Summary
The facility failed to ensure sufficient nursing staff and an effective staffing system were in place to meet resident needs. During an early morning observation, there were only three vehicles in the parking lot, minimal staff presence, and a call light was persistently ringing in a resident room. On the initial tour of the North, South, and East Wings, several residents were awake, and discrepancies were identified between staffing communication boards, staffing assignment sheets, and the staff actually present in the building. The midnight census was 129 residents, including two residents ordered for 1:1 sitter observation, while only four RNs and five CNAs were physically present. On the South Wing, the communication board and assignment sheet did not match, and the board was being updated for the oncoming shift. The assignment sheet documented one LPN and four CNAs for 53 residents, including two residents ordered for 1:1 supervision. When staff were checked, one CNA listed on the assignment could not be located, leaving one LPN and three CNAs for the 53-resident census with two residents requiring 1:1 supervision. One resident ordered for 1:1 supervision was observed lying in bed without staff present in the room, while another resident had a CNA assigned to 1:1 supervision, preventing that CNA from assisting other residents. Record review showed one resident had a physician order dated 2/26/2026 for 1:1 supervision, with no documentation in the record, no physician order, and no communication with the physician to discontinue it. Another resident had a physician order dated 3/19/2026 placing the resident on 1:1 observation due to fall risk until further notice, every shift. The assignment sheets did not contain documentation for a scheduled 1:1 sitter for the first resident on multiple overnight shifts, and did not contain documentation for a scheduled 1:1 sitter for the second resident on several overnight shifts. Staff interviews described repeated call-offs, inability to reach on-call staff, no night supervisor, and nurses and CNAs being assigned excessive numbers of residents, including one CNA reporting 22 residents and another reporting 28 residents alone on prior shifts. Residents and staff described delays in care and unanswered call lights. One resident reported waiting four hours for a call light to be answered, another reported waiting several hours to be changed, and others reported delayed medications and slow staff response. Staff also reported working doubles, 16-hour shifts, and whole floors of 56 patients, with assignment boards not being updated and staffing schedules containing inaccuracies. The staffing coordinator confirmed some staff appeared on the schedule for the wrong dates, and leadership acknowledged that the boards were not always updated and that there was no night supervisor in place.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment. During observations in the kitchen, surveyors found food debris and residue under food prep tables, missing floor tiles in multiple areas, holes in the walls, grease residue on the kitchen walls, dried food splatter on the walls and ceiling, and an accumulation of food debris and residue near the kitchen doorways. A live roach was observed crawling on the wall, and additional live roaches were seen crawling from behind a metal plate near the dishwashing area. Food debris was also observed on a cart used for food preparation. During interview, the Regional Dietary Manager stated that the kitchen condition was unsanitary and not in accordance with corporate standards. Review of the facility policy stated that food must be stored, prepared, distributed, and served in accordance with professional standards for food service safety.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to encode and transmit the discharge MDS assessment to the State within 7 days of assessment for Resident #136, who was discharged on 11/11/2025. Review of the resident’s MDS showed that a Discharge MDS Assessment was not documented. During interview, the LPN Lead MDS Coordinator stated that the resident’s discharge assessment was never done and that it would have had to be completed so it could register. The facility policy titled Resident Assessment Instrument states that annual, entry, discharge, and re-entry assessments are to be completed according to CMS Final Rule and RAI MDS Version 3.0 guidelines.
MDS Assessments Were Inaccurate for Three Residents
Penalty
Summary
Ensure each resident received an accurate assessment. Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and reflected residents' current status for 3 of 12 residents reviewed. For Resident #50, an observation showed the resident had no teeth, but the annual MDS was coded to indicate the resident did not have no natural teeth or tooth fragments. Staff C, LPN later stated the entry was marked incorrectly, and dental documentation from a local dental service indicated the resident had no teeth. For Resident #17, occupational therapy discharge documentation listed a history of TIA, bilateral foot drop, and left hemiparesis, but the significant change MDS coded lower extremity range of motion as no impairment and did not code TIA or hemiplegia in active diagnoses. Staff C, LPN stated the range of motion coding was incorrect and that TIA and hemiplegia should have been coded. For Resident #152, the clinical record showed admission for history of falls, muscle weakness, and adult failure to thrive, and staff interviews confirmed the resident was transferred to a local skilled nursing facility, but the MDS coded discharge status as home/community instead of skilled nursing facility. Staff F, LPN MDS stated the discharge status was coded in error.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and/or implement a comprehensive, person-centered care plan for Resident #8, who was documented as being under hospice care. During observation, the resident was sleeping in bed and did not respond when addressed by name. The DON stated the resident was on hospice and that a hospice care plan should have been in place. Record review showed the resident signed the hospice election form on 2/18/2026, and the Change in [NAME] form documented admission to hospice effective 2/18/2026, but the resident’s care plan did not document hospice services. The MDS Coordinator later stated the care plan had not been updated when the resident was placed under hospice care. The facility also failed to include care plan focus, goals, or interventions for Resident #17’s communication deficit and for Resident #28’s self-administration of medications. Resident #17 was observed to have limited expressive communication with mostly yes/no or single-word responses and delayed response time, and the medical record documented diagnoses including cognitive communication deficit, dysphagia, primary progressive multiple sclerosis, and other neurologic conditions. Resident #28 had physician orders for Chromium GTF and Nattokinase as supplements with unsupervised self-administration, and the MAR documented self-administration for both medications during March 2026, but the comprehensive care plan did not address the resident’s ability to safely self-administer medications. The MDS staff acknowledged that both the communication deficit and self-administration should have been care planned.
Failure to Provide Nail Care Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs for nail care for Resident #86, who was documented as requiring assistance with ADLs due to weakness and decreased mobility and as totally dependent on staff for personal hygiene. During an interview, the resident representative stated that the resident’s nails were not being cut and that the nails had been digging into the resident’s palm. The care plan dated 01/29/2026 identified the resident as unable to assist with ADLs and dependent on staff for personal hygiene. During observations, Resident #86’s right hand was contracted into a closed position, and the fingernails extended beyond the fingertips and touched the palm of the right hand. On a later observation, the resident had a brace on the right arm and a washcloth in the right hand, and the fingernails on the right thumb, second, third, and fourth fingers were approximately 1 to 1.5 inches long. A CNA stated that the resident’s nails were too long and that the CNA who gave the resident a bath last time should have cut the nails.
Missing medication dosage and undocumented wound dressing order
Penalty
Summary
The facility failed to obtain the medication dosage prior to administration for Resident #84. The physician order dated 3/10/2026 for Voltaren external gel 1% diclofenac sodium topical directed application to the knees before meals and at bedtime for pain, but the required dosage for application was not documented. The MAR for 03/01/2026 through 03/25/2026 showed the Voltaren gel was administered, and during interview the DON stated the Voltaren order did not have a dosage. The facility policy on medication administration required the six rights of medication administration to be followed, including the right dosage. The facility also failed to ensure wound care treatment orders and wound care were documented for Resident #157. The resident’s record showed diagnoses including fractures of the superior rim of the left pubis, non-displaced fracture of the anterior column of the left acetabulum, fracture of the sacrum, cirrhosis of the liver, and type 2 diabetes mellitus. During observation, the resident had a dressing on the right forearm dated 3/16/2026, but the physician orders did not include an order for a right forearm wound dressing. The Unit Coordinator stated she was not sure why the dressing was there and dated 3/16/2026, and noted there should be an order for a dressing and the nurse should follow the physician order. The progress notes did not contain documentation relating to the right forearm injury.
Improper Storage of Respiratory Delivery Devices
Penalty
Summary
Facility staff failed to ensure that nebulizer and oxygen delivery masks were stored after use in a manner consistent with professional standards of practice for 2 residents. Resident #84 was admitted with diagnoses including osteomyelitis, acute respiratory failure, and pneumonia, and had physician orders for arformoterol tartrate nebulization twice daily and budesonide inhalation twice daily. During observations on 3/23/2026, the resident’s nebulizer mask was seen lying across the nebulizer machine on the bedside table, open to air and not in a bag, both in the morning and again later that afternoon. The resident stated they received breathing treatments that morning, and the MAR documented both ordered nebulized medications were administered that morning. Resident #121 was admitted with diagnoses including chronic pulmonary obstructive disease and type 2 diabetes mellitus. During observations on 3/23/2026, the oxygen mask for inhalation of medications was found on top of the resident’s bed in the morning and again later that afternoon. The Unit Coordinator stated the mask should not be kept on the bed and should be placed in a storage bag. The facility policy titled Oxygen Administration stated that infection control measures included keeping delivery devices covered when not in use.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with a documented rate of 5.41% based on 2 errors out of 37 observations. During one medication pass, an LPN prepared an 81 mg chewable aspirin for a resident whose physician order was for Aspirin 81 mg delayed release, and the nurse stated she could not interchange the two different aspirin products and would need to look for the correct medication in the medication room. The resident’s order, dated 10/7/2025, directed Aspirin 81 Tablet Delayed Release 81 mg to be given once daily for heart health. During another observation, an LPN prepared Midodrine for a resident and read a pre-recorded blood pressure of 108/61 from a sheet on the medication cart. The nurse stated she would hold the Midodrine because of the resident’s blood pressure, but later stated the order was to hold only if systolic blood pressure was greater than 130 and that the medication should have been given. The resident’s order, dated 3/5/2026, directed Midodrine HCI 5 mg three times daily for hypotension and to hold for SBP > 130. The DON stated staff should not give a chewable aspirin when the order is for delayed release and should follow the parameters in the order rather than holding the medication incorrectly.
Unsecured, Expired, and Unattended Medications
Penalty
Summary
Drugs and biologicals were found unsecured and/or expired in multiple resident areas and medication carts. In Resident #155’s room, a bottle of Xlear Nasal decongestant and a bottle of extra strength Tums Antacid were observed on the bedside table unsecured on multiple observations. In Resident #156’s room, three unidentified pills in a plastic medication cup were observed on the bedside table unsecured on multiple observations. Staff H, an LPN, stated medications cannot be at the bedside unsecured, and the DON stated medications cannot be at the bedside unless they are self-administration medications and still need to be secure. Resident #28’s medication lockbox was observed unlocked and containing multiple expired medications, including Ubiquinol 100 mg softgels, Wobenzym N, Black Cumin Seed Oil, B12 Methycobalamin, and Probulin Probiotic. Resident #28 stated staff do not routinely check the medications in the box, and the DON stated nurses are expected to regularly check the medication box for proper storage, approved medication, and expiration dates. The facility policy on self-administration of medication stated nursing staff are responsible for proper rotation of bedside stock and removal of expired medications. Two medication carts also contained storage issues. On the North 1 cart, an expired Wixela inhaler with an open date of 2/9/2026 and an undated glucometer strip container were observed. On the North 2 cart, two glucometer strip containers were not dated. In another observation, an LPN left a medication cup labeled for one resident unattended on top of the medication cart while she entered another resident’s room to complete blood sugar testing and administer medications. The LPN stated she was doing two residents’ medications at a time and that the medication should not be left on top of the cart. The DON stated medication should be pulled only for the resident being given the medication and should never be left unattended.
Incomplete and untimely MAR documentation
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for 5 of 8 residents reviewed for medical records. The deficiency was based on multiple instances where the Medication Administration Record (MAR) did not show documentation for medications that were ordered for administration on specific shifts, including medications listed as one-time-daily, twice-daily, three-times-daily, every 8 hours, and sliding-scale insulin. The missing documentation was identified for Residents #11, #12, #14, #49, and #77 during record review. For Resident #11, the MAR for March 2026 did not document administration of several ordered medications on 3/10/2026 and 3/15/2026, including atorvastatin, potassium chloride ER, apixaban, a calorically dense oral supplement, and docusate sodium. During interview, the LPN stated the resident received all medications but that she forgot to go back and document them, explaining that she sometimes gave medications and did not document until the end of the shift and had a problem with timely documentation. For Resident #77, the MAR lacked documentation for multiple ordered medications on 3/10/2026 and 3/15/2026, including atorvastatin, melatonin, Plavix, Depakote, insulin glargine, metformin, metoprolol tartrate, potassium, baclofen, Lyrica, and trazodone. For Resident #14, the MAR did not document administration of finasteride, ropinirole, Secuado patch, trazodone, metformin, Risperdal, sotalol, and divalproex sodium on the same dates. For Resident #12, the MAR did not document administration of senna, trazodone, Colace, memantine, and Seroquel on 3/15/2026. For Resident #49, the MAR did not document administration of Claritin, Protonix, Lantus Solostar, and Novolin R sliding scale insulin on 3/5/2026. The DON stated that medications are expected to be charted after they are administered. The facility policy stated that each resident's medical record shall contain an accurate, complete, and timely representation of the resident's care and that each entry shall be dated, timed, and signed.
Hand Hygiene, Enteral Syringe Cleaning, Laundry Barrier, and PPE Deficiencies
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during medication administration. During an observation, an LPN exited one resident’s room and went to the medication cart to pour medications for another resident without performing hand hygiene. The LPN then entered the first resident’s room, did not perform hand hygiene, handed the resident medication and a Styrofoam cup of water, touched the straw, and exited the room without performing hand hygiene. The LPN then began to pour medications for a second resident and walked to that resident’s room without performing hand hygiene. The LPN later stated that hand hygiene should have been performed between residents, and the facility policy required hand hygiene between resident contacts and before preparing or handling medications. The facility also failed to ensure an enteral medication flush syringe was sanitized after use. During an observation, an LPN administered medication via a gastrostomy tube to a resident and did not rinse the flush syringe after finishing the medication administration, instead storing the syringe in a plastic package. The LPN stated the syringe should have been rinsed after use. The ADON and DON both stated the syringe should be washed and dried before being placed back into the packaging, and the facility policy addressed safe and effective medication administration via enteral feeding tubes. The facility failed to ensure an infection control barrier was maintained in the laundry room and failed to ensure appropriate PPE was used for a resident on transmission-based precautions. Observations showed the laundry room doors, including the soiled linen room door, were propped open while clean and soiled areas were accessible through the service hallway, and the Housekeeping Supervisor confirmed the soiled room door should not be open. In another observation, a CNA provided care to a resident with shingles who had an active order for contact isolation, but the CNA was not wearing a gown. The CNA stated staff had told her to be careful with the resident and acknowledged she should have had a gown on. The DON stated residents with shingles should be on contact precautions requiring gown, mask, and gloves.
Failure to Implement and Develop Comprehensive Care Plans for Metabolic and Behavioral Health Needs
Penalty
Summary
The facility failed to implement and document care plan interventions for two residents with specific medical and behavioral health needs. For one resident with a metabolic condition related to hypokalemia, the care plan required quarterly evaluations by a Registered Dietician (RD) to monitor caloric intake and assess nutritional needs. However, there was no documentation that the RD had completed these quarterly evaluations or made nutritional recommendations as indicated. The RD only reviewed residents who triggered for weight loss, and this resident had not triggered for such a review, resulting in the absence of required RD assessments. For another resident with a diagnosis of post-traumatic stress disorder (PTSD), the comprehensive care plan did not include a focus on PTSD or related behavioral health interventions, despite documentation in psychiatric and psychological notes of frequent flashbacks, nightmares, and significant distress. Both the DON and the Minimum Data Set Coordinator confirmed that the care plan lacked a focus on PTSD and acknowledged that it should have been included, as required by the facility's policy for comprehensive, person-centered care plans.
Insufficient Linen and Hygiene Supplies for Resident Care
Penalty
Summary
The facility failed to provide sufficient clean linens, washcloths, towels, and protective bed pads to meet the care needs of residents. Multiple residents reported having to wait for laundry delivery or lacking necessary items such as washcloths and towels, especially during the night shift when the laundry was not accessible. Staff interviews confirmed that certified nursing assistants (CNAs) and nurses frequently ran out of essential supplies before the end of their shifts, including gloves, washcloths, towels, and bed pads. Some staff reported bringing their own wipes for residents due to the shortage, and noted that laundry carts were sometimes empty at the start of their shifts. Observations of linen carts during the night shift revealed a limited number of protective bed pads available, with some carts containing as few as four to seven pads for the entire shift. Staff described difficulties in providing toileting care and maintaining resident hygiene due to the lack of supplies, and noted that the laundry room was locked and inaccessible during certain hours. The deficiency was corroborated by both resident and staff accounts, as well as direct observation of supply shortages.
Failure to Proactively Offer and Serve Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were offered and/or served to all residents in accordance with their needs, preferences, and requests, as required by facility policy. Multiple residents reported that snacks were not routinely offered to them in the evenings; instead, residents were expected to go to the nurses' station to request snacks. One resident, who is diabetic, stated that staff never came to offer snacks and that not all residents were able to go to the nurses' station, with another resident confirming that their roommate was unable to do so. Another resident, who experiences seizures and is photosensitive, reported that no one ever came to their room to offer snacks, and they did not like to leave their room due to their condition. Observations confirmed that snacks were stored in plastic containers at the nurses' stations, but staff interviews consistently indicated that snacks were only provided upon resident request, rather than being proactively offered. The facility's policy requires nursing staff to offer and serve snacks to all residents daily, in accordance with their needs and preferences, but this was not being followed. The deficiency was identified for all five sampled residents regarding the provision of evening snacks.
Incomplete and Inaccurate Behavior Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurate, specifically for a resident being monitored for mood and behaviors. Physician orders required detailed documentation of behavior monitoring, including specific codes for types of behaviors, interventions used, outcomes, and any side effects. However, the Treatment Administration Record for the resident only contained check marks and staff initials, lacking the required detailed information. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the documentation did not include the necessary coding or details about the resident's behaviors, as required by the physician's order and facility policy. Further review of the resident's progress notes revealed inconsistencies in documentation regarding medication refusal and behavioral observations. While the APRN noted that the resident was refusing medications, the progress notes also stated that no behaviors were observed during a shift. The facility's policies require accurate and complete documentation to reflect the resident's experiences and to monitor behaviors effectively. The deficiency was identified due to the lack of detailed and accurate documentation in the resident's medical record, contrary to both physician orders and facility policy.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with a serious mental disorder. The resident, who was admitted with a diagnosis of bipolar disorder, had their PASRR screening inaccurately documented with a depressive disorder instead of bipolar disorder. This discrepancy was identified during a review of the resident's admission records and clinical documentation, which did not include the bipolar disorder diagnosis on the PASRR screening dated 10/6/2023. During an interview, the Director of Nursing confirmed that the resident's diagnosis of bipolar disorder was not included in the PASRR screening, indicating a failure in accurately documenting the resident's mental health condition.
Improper Administration of Pain Medication
Penalty
Summary
The facility failed to administer narcotic pain medication according to professional standards of practice for two residents. Resident #73 had a physician's order for Tramadol to be given every 8 hours for a pain scale of 5-10. However, the Medication Administration Record (MAR) showed that Tramadol was administered multiple times when the resident's pain level was documented as zero or not applicable. This indicates that the medication was given outside the prescribed parameters, which was confirmed by interviews with staff who acknowledged the error. Similarly, Resident #318 had a physician's order for Hydrocodone-Acetaminophen to be given for chronic pain with a pain scale of 7-10. The MAR revealed that the medication was administered on several occasions when the resident's pain level was documented as 5 or 6, which is below the prescribed threshold. Staff interviews confirmed that the medication should not have been given for pain levels less than 7, and the Director of Nursing emphasized the importance of following physician orders. The facility's policy on medication administration requires verification of correct medication parameters, which was not adhered to in these cases.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely, as observed in one of the three halls. During observations, it was noted that a resident had bottles of vitamin C gummies and red grape seed vitamins on their bedside table. The resident confirmed that they took these supplements daily for circulation. Despite multiple observations over two days, the vitamins remained unsecured on the bedside table. A Licensed Practical Nurse (LPN) acknowledged that medications should not be at the bedside unless the resident has been assessed for self-administration, and even then, they must be secured. The Director of Nursing (DON) confirmed that residents are not allowed to have medications in their rooms without a physician's order for self-administration and a lockbox for secure storage. Another resident was observed with a tube of Diclofenac Sodium gel on their overbed table. The resident stated they kept the gel there for frequent use. The physician's order indicated the gel was to be applied daily for pain. The DON reiterated that residents should be assessed for self-administration, and if approved, medications should be stored in a lockbox. The facility's policy requires all drugs and biologicals to be stored in locked compartments, with specific procedures for bedside medication storage, which were not followed in these instances.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the kitchen and reach-in coolers, as observed during a survey. During an initial walk-through, assorted cut melon and other fruits were found in the reach-in cooler without identifying or date labels. Additionally, two 10-pound rolls of raw ground beef were left on the counter, not prepped in a pan or under running water, and there were uncovered and undated pans containing cake. Interviews with the Morning Charge and the Certified Dietary Manager (CDM) confirmed these observations. The Morning Charge acknowledged the mistake of placing raw ground beef on the counter instead of in the prep sink with running water. The CDM verified the lack of labeling on the fruit container and confirmed that the raw ground beef should have been under running water or prepped and covered. The CDM also confirmed that the dessert pans of cake should have been covered and dated, as per the facility's policy and procedure guidelines.
Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to proper personal protective equipment (PPE) protocols while providing high-contact care to residents under Enhanced Barrier Precautions. During an observation, the Infection Prevention Officer was seen applying a wound dressing to a resident's lower left leg without wearing a gown, despite the signage on the resident's door indicating the need for gloves and a gown during such high-contact activities. The resident had a physician's order for wound care and was under Enhanced Barrier Precautions due to a chronic wound and an indwelling medical device. Interviews with the Infection Prevention Officer and the Director of Nursing confirmed the lapse in protocol adherence. The Infection Prevention Officer admitted to not wearing a gown during the wound care procedure, acknowledging the requirement to use both gloves and a gown. The Director of Nursing reiterated the necessity of wearing a gown and gloves when providing direct wound care to residents on enhanced barrier precautions. The facility's policy on Enhanced Barrier Precautions, issued earlier in the year, clearly outlined the requirement for gown and glove use during high-contact resident care activities, including wound care.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge Healthcare And Rehabilitation Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Ocala Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Aviata At Arbor Springs | 1.1 mi | ★★★★★ | 7 | 0 |
| Palm Garden Of Ocala | 2.2 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Ocala | 2.5 mi | ★★★★★ | 8 | 0 |
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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 August 2026) and official state health department websites.