Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Balanced Healthcare during CMS and state inspections, most recent first.
Two residents with dementia, psychiatric diagnoses, moderate cognitive impairment, and documented behavioral issues were in a common area near the nursing station when one resident walked down the hallway and struck the other in the face while staff were seated at the desk charting. The aggressive resident had a care plan noting a history and potential for physical aggression and wandering into peers’ rooms, while the victim was care planned as a non‑aggressor with disruptive behaviors and impaired communication. Despite these known risks and a facility policy requiring protection from abuse and increased supervision of residents, supervision at the time was insufficient to prevent the resident‑to‑resident physical altercation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to a deficiency in infection control. One resident had unclear EBP signage and no physician order despite having a wound. Another resident with multiple pressure ulcers and an IV infusion lacked EBP signage and PPE, and there was no order for EBP. A third resident had EBP signage, but staff did not wear PPE, and there was no order for EBP. The facility's policy requires clear signage and allows nursing staff to initiate EBP empirically, but these measures were not followed.
The facility failed to maintain a clean and homelike environment, with issues such as stained curtains, peeling paint, and leaking AC units. Observations revealed debris in bathrooms, broken blinds, and non-functional sinks. Maintenance concerns were not promptly addressed due to a lack of work orders, and the Director of Maintenance was unaware of many issues. The facility's policy on maintaining a safe environment was not followed, impacting residents' living conditions.
A resident in a LTC facility did not receive consistent personal care, such as regular baths and hair washing, as outlined in her care plan. Despite her preference for bed baths and a restriction on male CNAs due to her psychological conditions, male CNAs provided care, contrary to the plan. Staff interviews revealed a lack of awareness of these care plan requirements, leading to unmet resident needs and a deficiency in care plan implementation.
Two residents in an LTC facility received inadequate wound care management. One resident had skin tears on his arms with bandages not changed regularly, despite a physician's order for daily dressing changes. Another resident had a skin tear on her eyebrow with an undated, soiled bandage and no physician order for changes. Staff interviews confirmed the lack of wound care consults and physician orders, contrary to facility policy.
A resident with moderate cognitive impairment and multiple diagnoses was observed smoking without a required adaptor, as per their care plan. Staff interviews revealed the adaptor was lost and not replaced, violating the facility's smoking safety policy.
A facility failed to adhere to standards of practice by using expired enteral nutrition formula for a resident with dysphagia and malnutrition. The expired formula was found in the resident's room and the nourishment room. Staff interviews revealed lapses in the review process for formula expiration, and the facility lacked a policy for managing enteral nutrition supplies.
Two residents did not receive their preferred and scheduled bathing care, leading to a deficiency in ADL services. One resident reported not having consistent baths or hair washing for weeks, while another had similar issues, with both receiving only three baths in 30 days. The DON acknowledged the limited baths but suggested a documentation issue. The facility's policy requires maintaining ADL abilities, which was not followed.
Failure to Adequately Supervise Residents Resulting in Resident‑to‑Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent a resident‑to‑resident physical altercation. On the date of the incident, one resident with dementia, behavioral disturbances, and a history of physical aggression approached another resident who was seated in a wheelchair near the nursing station and struck him on the right side of the face. Staff present at the nursing station, including an LPN and a CNA, were seated and charting when the aggressive resident walked down the hallway from the conference room area, stopped near the other resident, and delivered the punch. The incident was directly observed by at least one staff member, who reported seeing the blow and then intervening to separate the residents. The resident who was struck had multiple psychiatric diagnoses, including psychotic disorder with hallucinations due to a known physiological condition, generalized anxiety disorder, paranoid schizophrenia, recurrent moderate major depressive disorder, and pseudobulbar affect, and had a BIMS score of 9/15 indicating moderate cognitive impairment. His care plan identified him as a resident‑to‑resident non‑aggressor and documented numerous behavioral issues such as disruptive noises, wandering and sitting in various places in the halls, discarding food from meal trays, and calling 911 inappropriately, as well as impaired communication due to cognition. Progress notes and a psychiatry note documented that he was the victim in the altercation, that he denied pain and did not understand why he had been hit, and that he appeared at psychosocial baseline after the event. The resident who initiated the physical contact had diagnoses including unspecified dementia with behavioral disturbances, recurrent mild major depressive disorder, other specified persistent mood disorders, and generalized anxiety disorder, with a BIMS score of 11/15, also indicating moderate cognitive impairment. His care plan documented a history and potential for physical aggression related to dementia and poor impulse control, including prior incidents such as punching and breaking a bathroom mirror, striking a peer with a wet floor sign, slapping a peer, grabbing a peer by the wrist, pulling a fire alarm, attempting to remove a TV, and wandering into peers’ rooms to take items. Staff interviews confirmed that this resident frequently walked around, stole food, and entered other residents’ rooms, while the victim resident also walked the halls, yelled, and screamed. Despite these known behaviors and the facility’s abuse policy requiring protection from physical and psychosocial harm and increased supervision of residents, both residents were in a common area near the nursing station at the time of the incident without effective supervision that prevented the aggressive resident from approaching and striking the other resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were initiated for three residents, leading to a deficiency in infection prevention and control. Resident #237 was observed with a sign for EBP on the door, but the signage was unclear, and there was no physician order for EBP despite the resident having a wound. Similarly, Resident #163, who had multiple pressure ulcers and an intravenous medication infusion, did not have EBP signage or PPE outside the room, and there was no order for EBP. Resident #138 had EBP signage, but staff and emergency medics were observed not wearing PPE, and there was no order for EBP. The Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON) stated that residents were discussed daily during clinical morning meetings, and new orders for wound care, antibiotics, and catheters were reviewed. However, the ICP/ADON's list of residents requiring EBP did not include Residents #163, #237, or #138. The Director of Nursing (DON) acknowledged the missed opportunities to identify residents requiring EBP isolation. The facility's policy on Enhanced Barrier Precautions, implemented in October 2023, requires clear signage indicating the type of precautions and PPE required. Nursing staff are allowed to place residents on EBP empirically while awaiting physician orders, especially for residents with wounds or indwelling medical devices. The policy also states that EBP should be used for the duration of the resident's stay or until the wound heals or the device is removed. The failure to adhere to this policy resulted in the observed deficiencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment in several areas, including the 1 East wing, Lifestyle 2 unit, and the secured unit. Observations revealed numerous deficiencies such as stained and dirty privacy curtains, peeling paint, detached shower heads, and debris in shared bathrooms. Additionally, there were broken and missing window blinds, separated border trims, and brown and yellow substances on sinks. Residents reported non-functional sinks that had not been repaired for weeks despite maintenance being informed. Further observations highlighted issues with missing dresser drawers, dead cockroaches, food wrappers, and unidentified items on the floors. The facility also had problems with leaking air conditioning units, leading to water accumulation and potential safety hazards. Staff interviews revealed that maintenance concerns were not being addressed promptly due to a lack of work orders being submitted, and the Director of Maintenance was unaware of many of the issues due to not conducting regular room audits. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the numerous environmental concerns that were not promptly addressed. The maintenance and housekeeping teams were not effectively coordinating to ensure the facility's upkeep, leading to ongoing issues such as water leaks, damaged ceilings, and inadequate cleaning. The lack of communication and follow-up on maintenance requests contributed to the persistence of these deficiencies, impacting the residents' living conditions.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, leading to unmet personal care needs and a violation of resident rights. The resident expressed dissatisfaction with not receiving regular baths and hair washing, which she had requested. Despite her preference for bed baths due to her condition, these requests were not consistently fulfilled, indicating a lapse in the facility's adherence to the care plan. The resident's care plan included specific interventions due to her medical and psychological conditions, such as requiring two staff members for all care and no male CNAs due to her androphobia. However, the facility did not adhere to these interventions, as male CNAs were documented to have provided incontinence care, contrary to the care plan. This inconsistency was acknowledged by the MDS coordinator and the Director of Nursing, who noted that the resident had previously agreed to care from all staff but the care plan had not been updated to reflect this. Interviews with various staff members revealed a lack of awareness or misunderstanding of the resident's care plan requirements, particularly regarding the restriction on male CNAs. This lack of communication and adherence to the care plan resulted in the resident's needs not being met, highlighting a deficiency in the facility's implementation of a comprehensive care plan that respects resident preferences and rights.
Inadequate Wound Care Management for Two Residents
Penalty
Summary
The facility failed to provide adequate wound care management and treatment for two residents, leading to deficiencies in their care. Resident #378 was admitted with multiple medical diagnoses, including congestive heart failure and dementia, and had skin tears on his upper arms. Observations revealed that the bandages on his arms were not changed regularly, with one bandage dated several days prior and another soiled with red drainage. Despite a physician's order for daily dressing changes on his right elbow, there was no documentation of care for the wounds on his upper arms, and the wound care nurse was not informed of these injuries. Resident #377, who had a history of repeated falls and dementia, was observed with a bandage on her right eyebrow that was undated and soiled with dark drainage. There was no physician order for changing this bandage, and the wound care nurse was unaware of the injury. The resident had sustained a skin tear from a fall, and although progress notes indicated the bandage was changed once, there was no consistent documentation or treatment plan in place. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the lack of wound care consults and physician orders for the residents' injuries. The facility's policy required evidence-based treatments and physician orders for wound care, but these were not followed, resulting in inadequate care for the residents' wounds. The wound care nurse was not notified of the residents' conditions, and the facility's procedures for wound management were not adhered to, leading to the observed deficiencies.
Failure to Provide Smoking Adaptive Equipment
Penalty
Summary
The facility failed to ensure that smoking adaptive equipment was provided for a resident, leading to a deficiency in maintaining a safe environment. Observations on two separate occasions revealed that the resident was smoking without using a smoking adaptor, despite the care plan indicating the need for such equipment due to the resident's habit of smoking cigarettes down to the fingertips. The resident, who has moderate cognitive impairment and multiple diagnoses including Parkinsonism and paranoid schizophrenia, was at risk for smoking-related injuries. Interviews with staff members, including CNAs and LPNs, confirmed that the resident had not used a smoking adaptor for some time because it was lost and not replaced. The facility's policy requires that all safe smoking measures be documented and communicated to staff, and that supervision be provided as indicated in the care plan. However, the staff failed to adhere to these guidelines, as they did not ensure the resident had the necessary smoking adaptor before allowing him to smoke outside.
Expired Enteral Nutrition Formula Used for Resident
Penalty
Summary
The facility failed to provide enteral nutrition according to standards of practice by using expired nutritional formula for a resident. During an observation, it was noted that the resident's enteral feeding pump was off, and there were expired bottles of TwoCal HN 2.0 formula found in the resident's room. The resident had a history of dysphagia, unspecified protein-calorie malnutrition, and required attention to a gastrostomy. The enteral feed orders specified a daily feeding regimen, which was documented as administered daily according to the Medication Administration Record. Further investigation revealed that the expired formula was also present in the nourishment room where enteral feeding formulas were stored. Staff interviews indicated that both Central Supply and nursing staff were responsible for reviewing the formula upon receipt and use. However, the expired formula was not identified and removed in a timely manner. The Director of Nursing confirmed the issue, and it was noted that the facility lacked a policy related to enteral nutrition or the receipt of formula from Central Supply.
Failure to Honor Bathing Preferences and Schedules
Penalty
Summary
The facility failed to honor the bathing preferences and schedules for two residents, leading to a deficiency in the provision of Activities of Daily Living (ADL) care. Resident #51 reported not receiving consistent baths for weeks and not having her hair washed in over a month, despite her preference for bed baths and a scheduled bathing routine of three times a week. The facility's records showed that Resident #51 only received three baths in 30 days, which did not align with her care plan that indicated she required substantial assistance with most ADLs due to physical impairments. Similarly, Resident #100 also reported not receiving her scheduled baths and hair washing, with records indicating only three baths in 30 days, contrary to her care plan that required staff assistance for bathing and a preference for bed baths. The Director of Nursing acknowledged the limited number of baths provided to both residents but suggested it might be a documentation issue by the Certified Nursing Assistants. The facility's policy on ADLs, revised in 2021, mandates that residents' abilities in ADLs should not deteriorate unless unavoidable, and necessary services should be provided to maintain good grooming and hygiene. However, the facility failed to adhere to this policy, as evidenced by the discrepancies between the residents' care plans, their reported experiences, and the documented bathing tasks.
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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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Nursing homes near Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lexington Healthcare And Rehabilitation Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Alhambra Healthcare & Rehabilitation Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Eagle Lake Nursing And Rehab Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Marion And Bernard L Samson Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Gulf Shore Care Center | 2.7 mi | ★★★★★ | 10 | 0 |
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