Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Aviata At The Sea - Harbor Beach during CMS and state inspections, most recent first.
Food storage, sanitation, and temp control deficiencies were observed in the kitchen. Multiple frozen and refrigerated items were unlabeled, undated, or missing expiration dates, raw chicken was kept beyond the stated storage guidance, sanitizer in a red bucket measured 400-500 ppm, and the dishwasher rinse cycle was below the required temp. During tray line service, desserts and pudding were above safe cold temps, chopped pork loin was below the required hot-holding temp, and a cooked breaded chicken sandwich remained below the required reheat temp. A cook was also observed without proper facial hair covering.
Call lights were not kept within reach for three residents. One resident with anoxic brain damage, quadriplegia, and tracheostomy status had the call light attached to the bed headboard and could not reach it. A second resident with legal blindness and cognitive impairment had the call light on the floor on two observations and said staff sometimes did not give it to her when requested. A third resident with bilateral hand impairment and contractures had the call light in a nightstand drawer and could not reach it, despite care plans directing staff to keep the call light within reach.
Failure to provide daily grooming assistance: A resident with no cognitive impairment and ADL deficits related to a left hip fracture and weakness repeatedly requested a facial shave, but staff did not respond or offer shaving assistance when asked. Observations showed the resident continued to have long facial hair, and CNA interviews confirmed inconsistent follow-through with the facility’s grooming policy requiring daily shaving, hair combing, and nail care.
Failure to follow fall interventions and complete timely post-fall assessment for a resident with severe cognitive impairment and repeated falls. The resident had diagnoses of anemia and muscle weakness, a BIMS score indicating severe cognitive impairment, and a care plan with a low bed and bilateral floor mats after multiple falls. Observations showed the mats were not consistently positioned as ordered and the bed was not in the lowest position. Post-fall documentation was completed days after the fall instead of every shift for 72 hours as required.
A resident with anemia, dementia, and dysphagia had significant weight loss, but weekly weights were not completed consistently and a mismarked weight was accepted without reweighing to validate it. The resident’s record showed a drop from 162 pounds to 145.8 pounds over about 2 months, while the Dietitian, DON, and ADON described an inconsistent process for assigning and recording weekly weights.
Two residents had deficient G-tube care and medication administration. An RN failed to use a barrier, aspirate for residual, verify tube placement, clean the tube area, or keep the G-tube capped during care for one resident with anoxic brain damage and quadriplegia. For another resident with cachexia and muscle weakness, an RN crushed and gave oxycodone via PEG without first checking residual or placement and did not follow clean technique during the procedure.
Tracheostomy care was not performed according to policy for a resident with anoxic brain damage, quadriplegia, and chronic respiratory failure. An RN and an LPN had to be reminded to oxygenate the resident and apply the pulse oximeter, and they did not assess lung sounds or chest expansion. Staff also used clean rather than sterile technique for supplies, inner cannula handling, and suctioning, with multiple breaks in aseptic practice during the procedure.
Failure to Follow BID Seizure Medication Order: A resident with seizure dx and no cognitive impairment was ordered Lacosamide 50 mg PO BID, but MAR/MMCR review showed doses given only 4 hours apart on two occasions. An LPN and an RN both acknowledged that BID meds should be spaced 8 to 12 hours apart and that the doses were not given at the ordered interval.
Improper Storage of Medications and Wound Care Supplies: A large purse was observed in the med storage room next to resident antibiotics, and staff said personal items were kept there because there was no other place for them. In addition, a resident with a left foot wound had a bag of leftover dressing supplies on the meal table beside food and drinks, and staff interviews confirmed unused meds and dressing supplies were not supposed to be left at the bedside or kept in the room.
Failure to follow ordered meal portions and supplements: three residents with dysphagia, anemia, parkinsonism, and dementia were observed receiving meals that did not match their diet orders or meal tickets. One resident ordered a pureed diet with large protein portions and Magic Cup supplements but did not receive the supplement and was served only one scoop of protein; two other residents ordered large protein or large entree portions but were served only one scoop or standard portions instead.
Failure to Provide Dysphagia Advanced Meals in Proper Texture: Two residents on a Dysphagia advanced diet were observed receiving lunch items that did not match the ordered texture. Both meal plates included ground chicken, but the broccoli was served as large 2-3 inch florets that were not fork-mashable. The Kitchen Mgr stated broccoli on this diet needs to be chopped, and the SLP stated vegetables should be bite-sized and broccoli should be in smaller florets with no stems.
Improper dumpster waste disposal was observed in 2 of 2 observations. Two blue dumpsters were partially open or unsealed, with garbage bags broken open and spilling trash outside, along with medication containers, medical waste products, PPE, gloves, surgical masks, food boxes, and disposable plates around the dumpster area. The Kitchen Manager stated he oversees and cleans the dumpster area but did not know how often the outside blue dumpster was emptied.
Failure to follow EBP and wound care infection control practices. A resident with a PEG tube and severe cognitive impairment was transferred with a Hoyer lift by staff who did not wear gowns, and the lift was left in the hall without disinfection. Another resident with a sacral pressure ulcer, trach, PEG, and severe impairment had wound care performed with a soiled dressing placed in regular trash and contaminated gloves used to access clean dressing supplies. Staff acknowledged the improper PPE use, equipment handling, and dressing disposal.
A resident with severe sepsis and other conditions did not receive prescribed IV antibiotics during a three-day stay due to communication and procedural failures. Nursing staff failed to escalate the issue of undelivered medications, and the necessary high-cost authorization was delayed. The resident was discharged without receiving the required treatment.
The facility failed to maintain a sanitary and comfortable environment, with issues in the ice machine room, laundry room, main dining room, clean linen room, multiple resident rooms, community shower room, biohazard room, and outdoor patio. Observations included soiled floors, broken equipment, unsecured hazardous items, and poor maintenance reporting.
Five residents were treated undignifiedly, including a non-verbal resident watching his roommate eat without privacy, another frequently dressed in institutional gowns, a cognitively impaired resident eating with bare hands without staff intervention, and two residents served unappetizing pureed meals with derogatory comments from staff.
The facility failed to investigate an incident where a resident with multiple medical conditions sustained injuries of unknown origin. Despite complaints of pain and subsequent transfer to the hospital, there was no comprehensive nursing assessment or investigation into the cause of the injuries. Staff interviews revealed inconsistencies in documentation and communication, and the hospital later confirmed a shoulder dislocation.
The facility failed to assist two visually impaired residents with eating, resulting in inadequate food intake and potential risk for malnutrition. Both residents struggled to locate food on their trays and ate with bare hands, with no staff present to assist or supervise during meal times. The care plans lacked necessary interventions, and the staff were unaware of the residents' specific needs.
A resident with Diabetes Mellitus Type 2 was not identified or treated for her condition since admission, leading to a critically high blood sugar level. Despite being cognitively intact and partially dependent on assistance, the resident's care plan lacked orders for diabetes medication and blood glucose monitoring. The issue was only addressed after the resident's blood sugar was found to be 446, prompting immediate medical intervention.
The facility failed to consistently apply a physician-ordered left hand splint for a resident with multiple medical conditions, leading to a deficiency. Observations and interviews revealed that the splint was not applied as required, and staff admitted to inconsistencies in following the care plan.
The facility failed to manage a resident's Diabetes and overlooked a critical lab result for another resident. One resident did not receive insulin or blood glucose monitoring despite multiple physician visits, while another resident's critical low platelet count was not addressed during their stay.
The facility Physician failed to document visits in a timely manner for two residents, leading to deficiencies in medical record-keeping. One resident with diabetes and a foot ulcer had six visits documented as late entries, while another with liver cirrhosis and cancer had three visits documented late. The DON acknowledged these delays.
The facility failed to prepare pureed foods by methods that conserve nutritive value, flavor, and appearance for four residents with physician-ordered pureed diets. Observations revealed that the pureed foods were thin, watery, and unappetizing, leading to poor consumption by the residents. The Corporate Food Service Director acknowledged the issue but did not replace the unacceptable meals.
Food Storage, Sanitation, and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions during two tours of the central kitchen. In the central kitchen, surveyors observed multiple frozen and refrigerated food items that were unlabeled, undated, or missing expiration dates, including frozen meat patties, turkey patties, raw chicken pieces, unidentified frozen raw meat, raw pork, and a large box of raw chicken in the walk-in refrigerator. The kitchen manager stated that the raw chicken in the walk-in refrigerator had been placed there on 09/04/2025 and was used for Sunday’s meal and planned for that night’s meal. A review of the Food Safety Guide dated September 19, 2023, showed that raw chicken should be in the refrigerator for 1 to 2 days. Additional food service observations showed sanitation and temperature control issues. A Hydrion meter showed one red bucket contained sanitation solution between 400 and 500 ppm, above the normal range of 150 to 400. The hot temperature dishwasher rinse cycle measured between 170 and 175 degrees F, below the required 180 degrees F or above, and the kitchen manager stated he had been told the dishwasher needed to run a few times to reach the proper temperature before use. During a later tray line observation, chocolate cream pies and pureed chocolate pudding were found at 50 to 53 degrees F instead of 40 degrees F or below, a steam table pan of chopped pork loin measured 125 degrees F instead of 155 degrees F or above, and a cooked breaded chicken sandwich measured 85 degrees F and then 115 degrees F after reheating instead of 165 degrees F or above. Staff P was also observed in the food production area without a facial hairnet, and when he put one on it covered his beard but not his mustache.
Call Lights Not Kept Within Reach for Three Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for three residents. Resident #22, who had anoxic brain damage, quadriplegia, and tracheostomy status, was observed with the call light attached to the back of the bed headboard, out of reach. The resident indicated he wanted to use the call light but could not reach it, and he successfully activated it only after it was handed to him. The record noted he was totally dependent, could only use the call light when it was reachable, could not roll side to side, and had a care plan intervention stating the call light would be kept within reach. Resident #17, who had a diagnosis of legal blindness along with atherosclerosis, mild cognitive impairment, schizophrenia, and generalized muscle weakness, was observed with the call light on the floor and not within reach on two separate occasions. The resident stated that when she requested her call light, staff occasionally did not give it to her. Resident #1, who had bilateral hand impairment and contractures, was observed with the call light in a nightstand drawer and unable to reach it; the bed control was also on the floor away from the resident. The next day, the call light was observed attached to the bed and replaced with a softer touch call light. Each resident's care plan included keeping the call light within reach, but the observations showed it was not consistently accessible.
Failure to Provide Daily Grooming Assistance
Penalty
Summary
The facility failed to follow its own grooming policy for Activities of Daily Living for one resident who had no cognitive impairment and was admitted with a displaced intertrochanteric fracture of the left femur and muscle weakness. The policy stated grooming activities are to be offered daily and include shaving, combing hair, and nail care. The resident’s care plan identified an ADL self-care performance deficit related to impaired balance, left hip/pelvis fracture, and weakness, with interventions including bathing/showering and skin inspection. Survey observations and interviews showed the resident repeatedly requested facial shaving, but staff did not respond or provide shaving supplies or assistance when asked. On multiple observations, the resident still had long facial hair around the mouth and chin, and he stated he was still waiting for a shave and that no staff offered to shave him. CNA interviews reflected inconsistent responses about whether shaving was offered, with one CNA stating she had not had a chance to ask, another stating she would know by looking at the resident’s face, and another later providing a shave after noticing the resident’s facial hair was about 2 inches long.
Failure to Follow Fall Interventions and Complete Timely Post-Fall Assessment
Penalty
Summary
The facility failed to follow fall interventions for a resident with severe cognitive impairment and a history of multiple falls. Resident #23 was readmitted with diagnoses of anemia and muscle weakness, and the Quarterly MDS showed a BIMS score of 04. The care plan documented actual falls on 02/08/2025, 03/29/2025, and 07/22/2025, with interventions including a bed in low position, bilateral floor mats for safety, and determining and addressing causative factors of the fall. During observations on 09/08/2025 and 09/11/2025, the resident was seen in bed with one floor mat folded on one side and the other mat fully opened or folded on the opposite side, and the bed was not observed in the lowest position. The facility also failed to complete post-fall assessment documentation as required. The policy titled Fall Management stated that post-fall documentation should be initiated every shift for 72 hours, but the record showed post-fall assessments were completed on 07/28/2025, six days after the fall on 07/22/2025. In interview, the DON stated that after a fall the resident should be assessed, family and physician notified, care plans updated, and post-fall assessment completed every shift for 72 hours. A CNA stated that the resident was a fall risk and that the bed should be in the lowest position, fall mats should be on both sides of the bed, and the call light should be within reach.
Failure to Complete Weekly Weights and Recognize Significant Weight Loss
Penalty
Summary
The facility failed to attain weekly weights and identify significant weight loss in a timely manner for one resident who was admitted with anemia, dementia, and dysphagia and had a BIMS score of 12, indicating low to moderate cognitive impairment. The resident was observed eating lunch and consumed more than 75% of the meal. The weight record showed 162 pounds in July, 153 pounds in early August, 150 pounds later in August, an 08/11/2025 weight of 167 pounds that was later identified as mismarked, and 145.8 pounds in early September. These weights reflected a significant weight loss of 5.5% in one month and 10% in approximately two months. The nutrition care plan identified the resident as at risk for malnutrition and directed monitoring of weight and intake. The nutrition assessment documented significant weight loss and ordered weekly weights and Med Pass once daily, but the follow-up note assumed the 153-pound weight was erroneous and continued weekly weights without requesting a reweight to validate the 167-pound entry. No weekly weights were completed for nearly a month after 08/11/2025. A later dietary note again documented significant unplanned weight loss and suboptimal meal intake, and the resident was reported to tolerate the diet and supplement well. In interviews, the Dietitian stated weekly weights were tracked on an internal sheet and acknowledged uncertainty about why the weights were not in the system, while the DON and ADON described a process in which weekly weights were assigned among nursing staff and entered into the electronic record, with no specific staff member consistently responsible for taking them.
G-tube Care and Medication Administration Deficiencies
Penalty
Summary
Failure to follow professional standards for G-tube care and management was identified for 2 residents. Resident #22 was admitted with diagnoses including anoxic brain damage, candidiasis, and quadriplegia, and had physician orders for enteral feeding, stoma care, placement checks, and residual checks every shift. During observation of gastrostomy care, the RN did not place a barrier after disconnecting the feeding tube, causing spillage on the resident’s right upper thigh. The RN also did not aspirate for residual, did not check G-tube placement, did not clean the G-tube tip or the area around the tube before replacing the gown and bed cover, and the G-tube end tip was observed without a cap. Resident #52 was admitted with diagnoses including cachexia, muscle weakness, and contracture of the right hand, and had a BIMS score of 13. Physician orders included residual checks every shift and oxycodone 10 mg via PEG tube every 6 hours for chronic pain. During medication administration observation, the RN crushed the tablet, diluted it with water, and administered it through the PEG tube without first aspirating for residual or verifying tube placement. The RN did not clean the resident’s meal table before placing supplies on it, did not use a gown, and placed the syringe on the table inside a plastic bag. The RN stated residual and placement checks were only done in the morning, although the MAR showed a residual check documented at 12:00 PM and no documentation of a 9:00 AM residual check.
Tracheostomy Care Not Performed Using Required Respiratory Assessment and Sterile Technique
Penalty
Summary
Safe and appropriate respiratory care was not provided during tracheostomy care for one resident with anoxic brain damage, candidiasis, quadriplegia, and chronic respiratory failure with hypoxia and hypercapnia. The resident’s BIMS score was disabled on the most recent MDS assessment. During an observed tracheostomy care procedure, the RN and LPN donned PPE and performed hand hygiene, but they had to be reminded to oxygenate the resident before care and to apply the pulse oximeter. The RN stated the oxygen saturation was 95% five minutes before the procedure, but the resident’s respiratory status was not assessed by listening to lung sounds or observing chest expansion, as required by the facility policy. The observation also showed multiple breaks in tracheostomy care technique. The staff did not set up supplies on a sterile field and used clean technique to open supplies such as gauze, normal saline, and the tracheostomy care kit. The RN used regular gloves to change the inner cannula, while the LPN opened the inner cannula box in a way that did not maintain sterility. The RN placed normal saline on a table that was not a sterile field, used the saline during suctioning, and opened suction tubing on the resident’s abdomen. The suction kit contained only one sterile glove, and the RN had difficulty donning sterile gloves because they were too small. During the procedure, the resident coughed up light-yellow secretions, and the RN suctioned the tracheostomy using the suction tip multiple times, including inserting it back into the tracheotomy tube after being reminded not to do so. The staff were also reminded again to oxygenate the resident and to check oxygen saturation.
Failure to Follow Ordered Timing for Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident with a seizure diagnosis received Lacosamide according to the physician order and failed to follow the professional standard for the right time of medication administration. Resident #26 was admitted with diagnoses including seizure and cerebral infarction due to unspecified occlusion or stenosis of the right anterior cerebral artery. The resident’s most recent MDS assessment showed a BIMS score of 13, indicating no cognitive impairment. A physician order dated 01/24/25 and again documented on 09/10/25 ordered Lacosamide oral tablet 50 mg by mouth twice a day for seizures. Record review of the Medication Monitoring Control Record showed that the medication was administered with only a 4-hour interval on 09/03/25, when one dose was given at 12:35 PM and the second at 4:32 PM, and on 09/06/25, when one dose was given at 11:03 AM and the second at 4:00 PM. During interviews, an LPN stated that twice-daily seizure medication should be given 8 to 12 hours apart and acknowledged that the second dose should have been given by the night nurse after the first daytime dose. An RN also acknowledged that the interval must be 8 to 12 hours for a BID medication and stated she would pay more attention to physician orders and administer medications on the right time following the ordered interval.
Improper Storage of Medications and Wound Care Supplies
Penalty
Summary
The facility failed to keep the medication storage room free of staff personal belongings. During a tour of the medication storage room, a large black unzipped purse was observed sitting on the counter next to bags of residents’ antibiotics. Staff stated that facility staff leave personal items such as lunch boxes and purses in the medication storage room because the facility is very small and they do not have another place to keep them. The Director of Nursing stated that staff are not allowed to keep personal belongings inside the medication storage room. The facility also failed to properly store medications and wound care supplies for one resident. Resident #53 was admitted with diagnoses including acute osteomyelitis of the left ankle and foot, local infection of the skin and subcutaneous tissue, and Von Willebrand disease, and had a BIMS score of 15. The resident had an order for left posterior-lateral leg wound care with normal saline, calcium alginate, an abdominal pad, kerlix, and tape three times weekly and as needed. During observation, a large plastic bag of dressing supplies was found on the resident’s meal table next to food and drinks, containing normal saline, kerlix dressings, abdominal pads, and Vitamin D ointment sachets. The resident stated staff leave the supplies there and reuse the leftover dressing supplies at the next dressing change, while staff interviews stated unused dressing supplies and medications are not permitted to be left at the bedside or kept in the resident’s room.
Failure to Follow Ordered Meal Portions and Supplements
Penalty
Summary
The facility failed to follow the menus and resident-specific meal orders for 3 of 3 residents observed during dining observations. Resident #34 had diagnoses of dysphagia and anemia, a low BMI of 16.8, and a nutrition assessment recommending a large portion of protein with all meals and Magic Cup supplements twice a day. During the lunch observation, the meal ticket reflected a pureed diet, large entree portions, and a Magic Cup supplement, but the supplement was not provided and only one scoop of protein was served instead of a large portion. Resident #1 had diagnoses of dysphagia, anemia, and parkinsonism, with an order for a regular diet with dysphagia and mechanical soft large portions of protein for lunch and dinner. During the lunch observation, the meal ticket showed large portions of protein and ground baked ham, but the plate contained only one scoop of meat rather than the ordered large portion. Resident #10 had diagnoses of anemia and dementia, with an order for dysphagia, advanced texture, regular/thin liquids, and large entree portions with all meals. During the lunch observation, the meal ticket reflected a large entree, but the plate contained one serving of ground ham, 1/2 cup baked sweet potato, and 1/2 cup seasoned green beans, which did not provide the ordered large entree.
Failure to Provide Dysphagia Advanced Meals in Proper Texture
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs for 2 of 2 residents on a Dysphagia advanced diet, with the issue also having the potential to affect three residents on that diet. A review of the National Dysphagia Diet Levels noted that Level 3 Dysphagia advanced is a mechanical soft texture, including moistened ground meats and fork-mashable fruits and vegetables. Resident #55, who had diagnoses of Dementia and Dysphagia following Cerebrovascular Disease, was observed eating lunch in the main dining area with a meal ticket indicating a Dysphagia advanced diet, including chopped roasted broccoli florets and chopped ground bruschetta chicken. The meal plate, however, contained ground chicken and two large broccoli florets, 2-3 inches in size, that were not fork-mashable. Resident #10, who had diagnoses of Alzheimer's Disease and Unspecified Dementia, was also observed eating lunch in the main dining room with a meal ticket indicating a Dysphagia advanced diet, including chopped roasted broccoli florets and ground bruschetta chicken. The meal plate again contained ground chicken and two large broccoli florets, 2-3 inches in size, that were not fork-mashable. The Kitchen Manager stated that on the Dysphagia advanced diet, meat is ground and broccoli needs to be chopped because of its texture, and that the only way to provide broccoli on this diet is to overcook it, which they do not. Staff M, Speech Language Pathologist, stated that for the Dysphagia advanced diet, food needs to be chopped up and recognizable, vegetables need to be cut into bite-sized pieces, and broccoli needs to be in smaller florets with no stems.
Improper Dumpster Waste Disposal
Penalty
Summary
Improper disposal of garbage and refuse was observed in 2 of 2 observations. The facility policy titled Solid Waste Management, dated 11/30/2014, stated that solid waste shall be handled and disposed of in a manner that ensures a safe and sanitary facility environment. During an observation outside the main dumpster on 09/08/25 at 8:39 AM, two large blue dumpsters were partially open, with numerous bags of garbage and trash broken open and spilling their contents outside the dumpsters. Garbage, trash, medication containers, and medical waste products were observed on top of the blue dumpsters, and protective equipment, gloves, and surgical masks were noted around the garbage area. During a second observation on 09/09/25 at 8:45 AM, one blue dumpster was found unsealed and contained garbage bags, food boxes, disposable plates, and other trash, with dirty gloves and other trash around the area. In an interview on 09/10/25, the Kitchen Manager stated that he oversees the garbage dumpster area and cleans around it, but he did not know how often the blue dumpster outside was emptied.
Failure to Follow EBP and Wound Care Infection Control Practices
Penalty
Summary
The facility failed to follow CDC Enhanced Barrier Precautions (EBP) guidance for two residents. One resident had diagnoses including a displaced fracture of the left tibia, gastrostomy status, and dysphagia, and had severe cognitive impairment with a BIMS score of 7. Physician orders identified EBP related to the PEG tube, and the care plan included use of a mechanical lift for transfers due to weakness. During an observation, two staff members performed a Hoyer lift transfer without gowns, and both exited the room without wearing the PPE required for EBP. The Hoyer lift remained in the hall after the transfer without being disinfected during the observation period. A CNA later stated that she believed EBP was followed only for residents with PEG tubes and ostomies, and said she did not remember to use gown and gloves during the transfer. She also stated that no one had told her to disinfect the Hoyer lift after resident use and that she had never disinfected a Hoyer lift or other machine after each resident's use during her year at the facility. A second resident was re-admitted with diagnoses including an un-stageable sacral pressure ulcer, anoxic brain damage, chronic respiratory failure, quadriplegia, tracheostomy status, gastrostomy status, and hypertension, and had severe mental impairment. During observed wound care, an LPN removed the soiled sacral dressing and placed it in the resident's regular trash can instead of a biohazard container. The same nurse then used soiled gloves from the dressing change to touch the outside of a clean dressing supply cart and reach inside to retrieve gauze without first removing the contaminated gloves. Another LPN assisting with the procedure acknowledged that the soiled dressing should have been placed in the biohazard bin, and the DON later acknowledged that the dressing disposal and glove contamination were improper.
Failure to Administer Prescribed IV Antibiotics
Penalty
Summary
The facility failed to administer prescribed intravenous (IV) antibiotics to a resident, identified as Resident #1, during their three-day stay. The resident was admitted with severe sepsis and other complex medical conditions, including osteomyelitis, MRSA, and diabetes. Despite physician orders for three specific IV antibiotics, none were administered due to a series of communication and procedural failures within the facility. The nursing staff, including two Licensed Practical Nurses (LPNs), attempted to contact the facility's pharmacy to obtain the medications but were unsuccessful. They did not escalate the issue to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON), nor did they document the lack of medication delivery in the resident's records. The ADON had confirmed with the pharmacy that the medications were in stock prior to the resident's admission, but the high cost of the medications required additional authorization, which was not completed in a timely manner. The facility's pharmacist explained that the high-cost authorization form was not returned until the resident's last day at the facility, preventing the delivery of the medication. The Medical Director was not informed of the issue until the third day of the resident's stay, and by then, the resident had been discharged without receiving the necessary IV antibiotic therapy. The DON acknowledged that the facility did not administer the antibiotics as ordered, and there was no detailed documentation explaining the failure to deliver and administer the medications.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for residents. Observations revealed that the commercial ice machine room had a heavily soiled floor, missing floor area around the machine, and a large gap under the exit door, potentially allowing pests to enter. The laundry room had multiple issues, including a broken air-conditioning system, open barrier doors between soiled and clean areas, heavily soiled floors, rust-laden vents, and improper storage of washing chemicals on porous wood shelving. Additionally, one of the washing machines and one of the commercial dryers were non-operational, and the lint vent of the operational dryer was not being cleaned as per facility policy. The ceiling vent above the clean linen folding table was also contaminated with a black mold-like substance, posing a risk to clean clothes below it. Photographic evidence was obtained to support these findings. The main dining room was found to have several deficiencies, including a build-up of yellow/brown matter on the ceiling frame, a cracked ceiling light cover, and a light cover with a build-up of dried dead insects. The clean linen room was unsecured, with disposable razors and a bottle of hydrogen peroxide stored on the shelves, and the room was heavily soiled and stained. Multiple resident rooms were observed to be in disrepair, with soiled and peeling paint on over-bed tables, rust-laden bed frames, non-operational electric beds, and soiled walls and floors. Bathrooms in several rooms had issues such as offensive odors, continuously running toilets, broken toilet paper holders, and emergency call light cords wrapped around handrails. The community shower room had non-functional ceiling lights, and the biohazard room had a specimen refrigerator with a heavy ice build-up. The outdoor patio was also found to be in poor condition, with dead potted plants, peeling paint on the floor, a rust-laden wall fan, and a large hole at the entrance exit door, posing a trip/fall hazard. The facility's computerized TELS system for reporting housekeeping and maintenance issues was not being effectively utilized by staff, and the Housekeeping/Maintenance Log at the Nurses Station was not being properly used for reporting and documenting issues. These deficiencies were confirmed with the Administrator and the facility's Corporate District Manager during the environment tour and subsequent discussions.
Undignified Treatment of Residents
Penalty
Summary
Five residents were observed to be treated in an undignified manner by the facility. Resident #14, who is non-verbal and fed via a peg tube, was observed watching his roommate eat lunch without the privacy curtain closed. Resident #14 gestured his displeasure and indicated he wanted the curtain closed, but staff did not respond to his needs. Resident #33, who is also non-verbal and has significant physical limitations, was frequently observed wearing an institutional gown despite having personal clothes available. Staff did not dress him in his personal attire, which affected his dignity and emotional well-being. Resident #4, who has cognitive impairments and a history of schizophrenia and bipolar disorder, was observed eating meals with her bare hands without staff intervention. This led to food covering her face, body, table, and floor, causing discomfort to other residents who complained to the staff. Despite these complaints, staff did not assist Resident #4 in using silverware or provide appropriate supervision during meals. Residents #19 and #30 were served a pureed diet that was thin, watery, and mixed into an unappetizing brown slurry. An LPN made a derogatory comment about the meal in front of the residents and other staff, further diminishing the residents' dignity. Both residents ate less than 25% of their meal, indicating the poor quality and presentation of the food affected their intake. These observations highlight significant deficiencies in maintaining residents' dignity and providing appropriate care and supervision during meals.
Failure to Investigate Resident's Injuries
Penalty
Summary
The facility failed to investigate an incident where a resident sustained injuries of unknown origin. The resident, who had a history of multiple medical conditions including dislocation of the left shoulder joint, anxiety disorder, and atherosclerotic heart disease, was readmitted to the facility and later complained of left-hand pain and swelling. Despite the resident's complaints and subsequent transfer to the hospital, there was no comprehensive nursing assessment detailing the resident's pain level or injuries, and no investigation was conducted to determine the cause of the injuries. The Nurses' Progress Notes did not document how the fall occurred, and the Director of Nursing (DON) was unaware of any shoulder injury while the resident was at the facility. Interviews with staff revealed inconsistencies in the documentation and communication regarding the resident's condition. The Social Service Director (SSD) and a Licensed Practical Nurse (LPN) confirmed that the resident had a fall and was injured, but the LPN erroneously documented the resident's pain level as zero. The LPN also reported the transfer and injuries to the DON, who did not conduct an investigation into the cause of the resident's transfer to the hospital. The hospital records later confirmed that the resident sustained a shoulder dislocation, which was reduced in the emergency department. The lack of a thorough investigation and proper documentation highlights the facility's failure to respond appropriately to the alleged violation.
Failure to Assist Visually Impaired Residents with Eating
Penalty
Summary
The facility failed to provide necessary assistance and supervision to maintain the independent eating abilities of two residents, both of whom were visually impaired. During the breakfast and lunch meals, Resident #5 was observed struggling to locate food on the tray and eating with bare hands, resulting in significant agitation and minimal food consumption. The CNA did not reposition the resident into an upright eating position or provide any guidance on the location of the food items. The resident consumed less than 25% of both meals, and the CNA did not return to assist during the meal times. Additionally, the resident's care plan lacked specific interventions for assistance with eating despite the resident's visual impairment and risk for malnutrition, as evidenced by a notable weight loss over time. Similarly, Resident #13, who shared a room with Resident #5, also struggled to find food on the tray and ate with hands during the breakfast and lunch meals. The resident was observed naked from the waist down and reaching over the overbed table to grab food, resulting in spilled food on the body and bed. The room door was shut, and no staff were present to assist or supervise the resident. The DON confirmed the surveyor's findings and acknowledged that the nursing staff were unaware of the care plan interventions, which included providing food in mugs to maintain the resident's independence in eating. Both residents had documented visual impairments and required specific dietary interventions to support their nutritional needs. However, the facility staff failed to implement these interventions, leading to inadequate food intake and potential risk for malnutrition. The care plans for both residents did not include necessary interventions for assistance with eating, and the staff were not adequately trained or informed about the residents' needs, resulting in a significant deficiency in the quality of care provided.
Failure to Identify and Treat Diabetes
Penalty
Summary
The facility failed to identify and treat a resident with Diabetes Mellitus Type 2, leading to a significant deficiency in care. Resident #17, who was admitted with a diagnosis of Diabetes Mellitus Type 2 and a diabetic foot ulcer, had not received any insulin or blood glucose monitoring since admission. Despite being cognitively intact and partially dependent on assistance for daily activities, the resident's care plan included an intervention to medicate as ordered, but no orders for diabetes medication, fingersticks, or lab results were present. The resident expressed concern about not receiving insulin or having her blood glucose levels checked, which she had been receiving in the hospital prior to admission. The staff informed her that they needed an order to check her blood sugar, but no such order was obtained until the issue was escalated on 05/08/24. Interviews with the Director of Nursing (DON) and the Medical Director, who was also the resident's Primary Care Physician (PCP), revealed a lack of communication and follow-up regarding the resident's diabetes management. The DON confirmed the absence of orders for blood glucose monitoring and diabetes medication. The PCP admitted that the resident had refused labs at one point but did not follow up on the need for blood glucose checks. The primary nurse for Resident #17 was unaware of her diabetic condition due to the lack of medication orders. It was only after the resident's blood sugar was found to be critically high at 446 that immediate medical intervention was initiated, including orders for insulin, Metformin, and daily blood sugar checks.
Failure to Apply Physician-Ordered Splints
Penalty
Summary
The facility failed to provide the physician-ordered left hand splint for a resident with multiple medical conditions, including hemiplegia, muscle weakness, and contractures. Observations on different days revealed that the resident was not wearing the prescribed left hand splint, despite physician orders stating it should be worn up to 6 hours daily. The resident, who is alert but non-verbal, confirmed through gestures that the splint was not being applied as required. The resident's care plan also documented the need for adaptive devices to prevent contractures, but these were not consistently used. Interviews with staff and the resident's Power of Attorney (POA) indicated inconsistency in the application of the splints. Staff members admitted that the splints were sometimes applied and sometimes not, with one staff member stating that the responsibility for applying the splints had shifted from a restorative nurse to Certified Nursing Assistants (CNAs). The POA expressed concerns about the attentiveness of the staff to the resident's health needs, noting that not all staff were diligent in following the care plan. This inconsistency in care led to the deficiency noted in the report.
Failure to Address Diabetes and Critical Lab Results
Penalty
Summary
The facility Physician failed to identify and treat a resident with Diabetes and failed to address a critical lab result for another resident. Resident #17, who was admitted with Diabetes Mellitus Type 2 and a Diabetic foot ulcer, did not receive any insulin or have her blood glucose levels checked since admission. Despite being seen by the physician multiple times, there were no orders for diabetes management, and the resident expressed concern about not receiving insulin or having her blood sugar monitored. The Director of Nursing confirmed the lack of orders, and the Medical Director acknowledged the oversight, stating that the resident's care fell through the cracks. Resident #157, admitted with Cirrhosis of the Liver and Liver Cancer, had a critical low platelet level that was not addressed. The resident's lab results showed a critical low platelet count, but the physician's progress notes did not mention this critical value. The resident was seen by the physician three times during the stay, but the critical lab result was overlooked, leading to a lack of appropriate medical response to the resident's condition.
Physician's Failure to Timely Document Visits
Penalty
Summary
The facility Physician failed to document visits in a timely manner for two residents, leading to deficiencies in medical record-keeping. Resident #17, who was admitted with Diabetes Mellitus Type 2 and a diabetic foot ulcer, had six physician visits documented as late entries, with significant delays between the actual visit dates and the documentation dates. For instance, a progress note dated 04/13/24 was created on 12/19/23, and another dated 04/29/24 was created on 05/07/24. This delay in documentation does not comply with the facility's policy, which requires timely recording of physician visits and progress notes to ensure continuity of care and compliance with state and federal regulations. Similarly, Resident #157, who was admitted with cirrhosis of the liver and liver cancer, had three physician visits documented as late entries. The progress notes for visits on 12/06/23, 12/11/23, and 12/13/23 were created much later, with the latest entry being made on 04/18/24. The Director of Nursing acknowledged these delays during an interview, confirming the physician's failure to document visits promptly. This lack of timely documentation compromises the quality of care and adherence to regulatory requirements.
Failure to Prepare Nutritious and Palatable Pureed Foods
Penalty
Summary
The facility failed to prepare pureed foods by methods that conserve nutritive value, flavor, and appearance for four residents with physician-ordered pureed diets. During an observation of the lunch meal in the main kitchen, the surveyor noted that the pureed foods, specifically the Pureed Cheese Ham & Macaroni Casserole and Pureed Sauteed Spinach, were very thin and watery. The lunch cook was unaware that adding too much liquid to the pureed food mixture decreases its nutritional value and negatively affects its appearance and taste. Additionally, no pureed garnishes were used to enhance the appearance of the pureed foods. The Corporate Food Service Director (CFSD) acknowledged that the pureed foods were unacceptable but failed to replace them with acceptable alternatives for the lunch meal. Residents #19 and #30 were observed struggling to consume the watery pureed food, with one staff member mixing all the foods together into a slurry and failing to offer beverages between bites. Both residents consumed less than 25% of their lunch meal. Resident #5, who is visually impaired, was observed attempting to eat the watery pureed food with her hands, resulting in a mess on her face, body, tray, and floor. During a breakfast meal observation, the pureed foods served to Residents #19 and #30 were again noted to be thin, watery, and running into each other on the plate. The CFSD acknowledged that the pureed fortified hot cereal was not acceptable and stated that the recipe would be reviewed with the cook. The facility's diet census confirmed that there were four residents with physician-ordered pureed diets, including Residents #5, #7, #19, and #30. Clinical records for these residents indicated various diagnoses and dietary needs, including dysphagia, cognitive impairments, and the need for fortified foods. Despite these needs, the facility consistently failed to provide pureed foods that met the required standards for consistency, nutritional value, and appearance.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 342 citations issued within 25 miles in the last 12 months — including the 4 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.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Lauderdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broward Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Pearl At Fort Lauderdale Rehabilitation And Nursin | 4 mi | ★★★★★ | 0 | 0 |
| Westlake Nursing And Rehab Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Wilton Manors Healthcare & Rehabilitation Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Plantation Nursing & Rehabilitation Center | 4.8 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.