Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Baya Pointe Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete discharge documentation for a resident: The facility failed to accurately and completely document where a resident was discharged, including missing Resident/Representative Acknowledgement information and unclear identification of the discharge destination. A social worker note stated the resident wanted to go home to an address not listed on the admission record and that his brother would pick him up, while staff interviews showed uncertainty about which brother transported him and the DON stated the discharge location should have been documented.
A resident with cognitive impairment and multiple diagnoses had discharge paperwork that listed an incorrect discharge location and omitted the discharge disposition, date, and time of discharge. Social work notes indicated the resident wanted to go home and that his brother would pick him up, but staff interviews showed uncertainty about the actual discharge destination, and the DON stated the location should have been accurately documented on the Discharge Summary.
Failure to Post Current Nurse Staffing Information: The facility did not ensure the daily nurse staffing posting was current and accurate for residents, staff, and visitors. During observation, the posted staffing information was outdated, and the DON acknowledged it had not been updated since the prior Friday. The facility policy required the BIPA staffing posting to be completed each day, displayed in a visible location, and reflect actual staff on duty with updates as changes occur.
A resident had multiple active physician orders for wound care to the buttocks and right lateral thigh, including topical medications and specific dressing protocols, to be completed on the night shift. Review of the Treatment Administration Record showed missing entries for all ordered wound care and topical antibiotic applications on two consecutive nights. The DON acknowledged that blank TAR entries indicate care was either not done or not documented, and two LPNs stated they performed the wound care on those nights but forgot to chart it. This conflicted with the facility’s documentation policy requiring complete and accurate recording of all services provided.
Nursing staff failed to administer a prescribed blood pressure medication to a resident with multiple chronic conditions, withholding doses without physician notification or proper documentation, despite facility policy requiring such actions when medications are not given as ordered.
Two residents did not receive oxygen therapy as ordered, including one with a tracheostomy who was given oxygen without required humidification and another with COPD who received a higher oxygen flow rate than prescribed. Staff interviews confirmed that physician orders and facility policy for oxygen administration were not followed.
Staff did not follow enhanced barrier precautions during incontinence care for a resident with a gastrostomy tube, as both an LPN and a CNA provided care without wearing gowns despite clear orders and signage. Additionally, an LPN failed to perform hand hygiene during multiple medication administrations, including before and after donning gloves and between resident contacts, contrary to facility policy and CDC guidelines.
A resident with an open wound was placed on Enhanced Barrier Precautions, but an LPN provided wound care using only gloves instead of the required gown and gloves. Facility policy and staff interviews confirmed that both gown and gloves are mandated for such care to prevent the spread of multidrug-resistant organisms.
The facility failed to provide prescribed therapeutic diets, specifically Health Shakes, to three residents. Observations and interviews revealed that the facility frequently runs out of Health Shakes, leading to significant weight loss in residents. Despite meal tickets indicating the inclusion of Health Shakes, they were often missing from meal trays.
The facility failed to ensure accurate and complete medical records for several residents, leading to deficiencies in nutrition and skin condition management. Residents did not receive prescribed supplements, and there were gaps in documentation for skin assessments and wound care. Staff interviews revealed inconsistencies in understanding responsibilities, contributing to incomplete records.
The facility failed to ensure proper hand hygiene during medication administration, wound care, and meal service, did not clean medical equipment between uses, and did not follow infection control standards for urinary catheter care, increasing the risk of infection.
The facility failed to ensure a safe environment for residents by improperly storing and handling oxygen equipment. Observations revealed oxygen concentrators and tanks in residents' rooms without current orders for oxygen therapy, posing safety hazards. The DON acknowledged the improper storage and confirmed the removal of discontinued equipment.
The facility failed to ensure privacy for a resident during wound care. An RN entered a resident's room without closing the door or blinds, exposing the resident to potential visibility from staff members in the parking lot. Another staff member interrupted the wound care, further compromising privacy. The RN acknowledged the oversight, and the DON confirmed that staff should ensure privacy during care.
The facility failed to ensure a clean and homelike environment in the 300 Hall and main dining room. Observations included black lines on walls, peeling wallpaper, a stained bed linen, and missing floor tiles. The Maintenance Director and Administrator confirmed these issues but were either unaware or attributed them to wear and tear.
The facility failed to ensure that a resident with a newly evident serious mental disorder was referred for assessment. A resident diagnosed with paranoid schizophrenia did not have a new Level I PASARR conducted after the diagnosis. The Social Services Director confirmed the need for a new screening, and the DON stated the facility lacked a PASARR policy and followed the RAI.
A facility failed to develop a person-centered care plan for a resident with epilepsy, despite having physician orders for medication. The care plan lacked focus and intervention for managing the resident's seizure disorder, which was confirmed by the MDS Coordinator.
The facility failed to change a resident's PICC line dressing as per policy, leaving it unchanged for over 10 days despite the requirement for weekly changes. The resident had multiple serious diagnoses, and the failure to follow physician orders and facility policy resulted in a deficiency in care.
The facility failed to ensure that a resident receiving dialysis services had their vitals documented upon return from the dialysis clinic, as required by the physician's order. Multiple instances of missing documentation were noted, and staff interviews confirmed the oversight. The resident's care plan indicated a need for hemodialysis due to renal failure, making accurate documentation crucial.
The facility failed to post daily nurse staffing data. The posted information was outdated, and the new receptionist was unaware of the correct procedure. The Staff Coordinator, who usually updates the data, was on vacation, leading to the oversight. There was no written policy, and the facility followed federal guidelines.
The facility failed to ensure food items were stored in accordance with professional standards for food safety. Opened boxes of cereals and a container of ice cream were found without labels indicating the open date or resident name. The Certified Dietary Manager confirmed the items were not labeled as required by the facility's policy.
Incomplete discharge documentation for a resident
Penalty
Summary
The facility failed to maintain accurate and complete discharge records for one resident. The resident’s discharge summary documented the discharge location as the resident’s home address and the Responsible Party/daughter’s home address, but there was no documentation of the resident’s name or the Responsible Party/daughter’s name in the section designated for Resident/Representative Acknowledgement. A social worker progress note stated that the resident wanted to discharge home to an address not listed on the admission record and that the resident’s brother would be picking him up from the facility. During interviews, the Director of Social Work stated that the resident wanted to leave and did not trust his daughter, and that the discharge assessment was completed with the address where the resident was going after discharge. An LPN Unit Manager stated the resident left with his brother, but could not remember the brother’s name and was unsure which brother picked him up. The DON stated the discharge location should have been documented and that knowing where a resident is being discharged is required for a safe discharge and is expected to be accurately documented on the Discharge Summary. The facility policy required the resident and/or representative to be notified in writing of the location to which the resident is being transferred or discharged.
Incomplete and inaccurate discharge documentation
Penalty
Summary
The facility failed to maintain an accurate and complete clinical record for one resident discharged from the facility. The discharge documentation listed an incorrect discharge location, naming the resident’s home address and the responsible party/daughter’s home address, while the record did not document the resident’s discharge disposition or the date and time he left the facility. The discharge summary also did not contain the resident’s name or the responsible party/daughter’s name in the section designated for resident/representative acknowledgement. The resident had diagnoses including other sequelae of cerebral infarction, alcohol dependence with alcohol-induced persisting dementia, presence of other vascular implants and grafts, and difficulty walking. His MDS documented a BIMS score of 7 out of 15, indicating cognitive impairment. Social work notes showed the resident stated he wanted to discharge home to an address not listed on his facesheet and that his brother would pick him up, while another note documented an attempt to contact the brother regarding discharge. Staff interviews reflected uncertainty about which brother took the resident and where he actually went, and the DON stated the discharge location should have been documented for a safe discharge and accurately recorded on the Discharge Summary.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure current and accurate nurse staffing data was posted daily for residents, staff, and visitors. During an observation on Friday, 5/4/2026 at 9:31 AM, the posted nurse staffing information was dated Friday, 5/1/2026. During an interview at the same time, the DON acknowledged that the staffing information posted on Monday, 5/4/2026 at 9:31 AM was not current and had last been updated on Friday, 5/1/2026. The DON stated the scheduler was responsible for ensuring the posted nurse staffing information remained accurate and current throughout the weekend. Review of the facility's Care Staffing Policy, revised 10/2025, stated that the daily staffing posting required under BIPA must be completed each day, displayed in a visible location near the main entrance or front desk, and reflect actual staff on duty with updates as changes occur.
Failure to Accurately Document Wound Care on Treatment Administration Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for a resident receiving multiple wound care treatments. Physician orders for this resident included specific wound care to the right buttock starting 12/17/2025, to the left buttock starting 12/29/2025, and to the right lateral thigh starting 01/06/2026, as well as an order for triple antibiotic ointment to the right buttock starting 11/19/2025. Review of the January 2026 Treatment Administration Record (TAR) showed no documentation on the night shift for the ordered right buttock wound care, left buttock wound care, right lateral thigh wound care, or the triple antibiotic ointment on 1/9/2026 and 1/10/2026, despite the orders being active on those dates. During interviews, the Director of Nursing stated that an empty space on the TAR means either the nurse did not perform the wound care or forgot to document it, and that nurses are expected to document wound care when completed. One LPN reported always performing the resident’s wound care and stated that wound care was completed on January 9 but was probably not charted. Another LPN stated that wound care was performed on January 10 but was not documented. The facility’s documentation policy, revised in January 2024, requires that services provided to residents be documented in the medical record and that documentation be complete and accurate, which was not followed in this case.
Failure to Administer Medication as Ordered and Notify Physician
Penalty
Summary
A deficiency occurred when nursing staff failed to administer Entresto, a blood pressure medication, as ordered by the physician for a resident with diagnoses including end stage renal disease, chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and essential primary hypertension. The physician's order specified that Entresto should be given twice daily, but the medication administration record showed that doses were withheld on multiple occasions, marked as 'outside parameters,' without any documented parameters for withholding the medication. Nursing and medication administration notes for the relevant period did not contain documentation that the physician was notified when the medication was not administered. Interviews with the RN and LPN involved revealed that they held the medication due to low blood pressure, despite the absence of specific parameters in the order, and did not notify the physician or document the rationale as required by facility policy. The facility's policy states that if a drug is withheld, the reason must be documented and the physician and responsible party notified, which was not done in this case.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents receiving oxygen therapy. One resident with a tracheostomy and multiple respiratory diagnoses, including acute and chronic respiratory failure, was observed receiving oxygen via tracheostomy mask at 4 liters per minute with a humidification bottle that was empty on two separate occasions. Physician orders specified the use of humidified oxygen and regular changing of the humidification bottle, but these were not followed. Staff interviews confirmed that the humidification bottle should not have been empty and that staff are responsible for ensuring proper oxygen delivery and humidification. Another resident with chronic obstructive pulmonary disease (COPD) and other comorbidities was observed receiving oxygen at 4 liters per minute via nasal cannula, while the physician order specified oxygen at 2 liters per minute as needed for shortness of breath. The oxygen concentrator was also not within the resident's reach during observations. Staff confirmed the discrepancy between the ordered and administered oxygen flow rate and were unaware of how the error occurred. Facility policy required staff to review physician orders and ensure the correct oxygen flow, but this was not adhered to in these cases.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow infection control standards for enhanced barrier precautions during incontinence care for a resident with a gastrostomy tube and a physician's order for enhanced barrier precautions. During an observation, both an LPN and a CNA provided incontinence care to the resident without wearing gowns, despite signage and care plan instructions indicating the need for gown and glove use during high-contact care activities. Both staff members acknowledged in interviews that they were aware of the requirement to wear gowns and gloves but did not do so during the care provided. Additionally, hand hygiene protocols were not followed during multiple medication administration observations. An LPN was observed handling the medication cart, computer, and resident care supplies, as well as entering and exiting resident rooms, without performing hand hygiene at any point before donning gloves, after removing gloves, or between resident contacts. The LPN also failed to perform hand hygiene before and after administering medications, performing blood glucose checks, and handling insulin, despite facility policy and CDC guidelines requiring hand hygiene at these points of care. The resident involved in the enhanced barrier precautions deficiency had a recent admission with medical diagnoses including a gastrostomy tube, and the care plan specifically required enhanced barrier precautions during high-contact care activities due to the presence of an indwelling medical device. Facility policies reviewed confirmed the need for gown and glove use for such residents and outlined the importance of hand hygiene before and after resident contact and invasive procedures. Staff interviews confirmed knowledge of these requirements, but the observed practices did not align with facility policy or infection control standards.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) while providing wound care to a resident who was on Enhanced Barrier Precautions (EBP). The resident had been admitted with an unspecified open wound on the right knee. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care for the resident while only wearing gloves, despite a sign indicating the need for EBP, which requires both gown and gloves for high-contact care activities such as wound care. Interviews with the LPN and the Director of Nursing confirmed that the facility's policy mandates the use of both gown and gloves for residents on EBP, particularly during direct care activities like wound care. Review of the facility's policies further supported that EBP is required for residents with wounds, and that staff should adhere to these infection control standards to prevent the transmission of multidrug-resistant organisms. The failure to follow these procedures was directly observed and acknowledged by staff.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure residents received prescribed therapeutic diets, specifically Health Shakes, for three residents. Resident #58, who has stage 3 chronic kidney disease and other conditions, did not receive the prescribed Health Shake on multiple occasions. Observations on 5/6/2024 and 5/7/2024 confirmed the absence of Health Shakes on the resident's meal trays. The resident experienced significant weight loss over the past 180 days, and the facility's records showed inconsistent documentation of Health Shake intake. Interviews with staff revealed that the facility frequently runs out of Health Shakes, and there was a lack of communication regarding the shortage on specific days. Resident #9, who is on a dysphagia advanced diet, also did not receive the prescribed Health Shake during meals on 5/6/2024 and 5/7/2024. Despite the meal tickets indicating the inclusion of Health Shakes, they were missing from the trays. The resident's medical record showed significant weight loss over the past 180 days. The Registered Dietician acknowledged that the facility runs out of Health Shakes at times, particularly on Mondays before the weekly delivery. Resident #68, who is on a pureed diet, did not receive the prescribed Health Shake during breakfast on 5/7/2024. The meal ticket indicated the inclusion of a Health Shake, but it was not present on the tray. The resident's medical record showed consistent documentation of Health Shake intake, but the Dietary Manager confirmed that the facility ran out of Health Shakes on 5/6/2024 and 5/7/2024. The facility's Quick Reference Guide outlines the importance of nutritional supplements for residents with insufficient nutrition intake, but the facility failed to maintain an adequate supply of Health Shakes to meet residents' needs.
Deficiencies in Medical Record Accuracy and Completeness
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for several residents, leading to deficiencies in nutrition and skin condition management. For instance, Resident #58 did not receive the prescribed Health Shake supplement on multiple occasions due to the facility running out of stock. Despite this, the Medication Administration Record (MAR) inaccurately showed that the resident consumed 100% of the Health Shake on those days. The Dietary Manager confirmed the shortage and lack of inventory management for Health Shakes, which contributed to the inconsistency in resident care documentation. Resident #1's medical records were incomplete, with missing weekly skin integrity reviews and inconsistent documentation of skin assessments and dressing changes. The resident had multiple physician orders for skin and wound care, including monitoring a pacemaker site and performing weekly skin sweeps. However, several weekly skin assessments were not documented, and there were discrepancies in the records regarding the condition of the resident's skin. Interviews with staff revealed that nurses and CNAs had different understandings of their responsibilities for skin assessments, leading to gaps in documentation and care. Similar issues were observed with other residents, such as Resident #9 and Resident #68, who did not receive their prescribed Health Shakes, yet their MARs indicated full consumption. Additionally, Resident #55 had incomplete documentation for wound care and weekly skin assessments, with several entries missing or inaccurately recorded. Resident #227 had a port with a bandage that was not dated, and there were no physician orders for port care documented. These deficiencies highlight significant lapses in the facility's documentation practices, affecting the accuracy and completeness of medical records for multiple residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during various activities, including medication administration, wound care, and meal service. Observations revealed that staff did not wash their hands between serving residents in the dining room, nor did they perform hand hygiene before and after medication passes. Additionally, medical equipment such as blood pressure cuffs was not cleaned between uses on different residents, increasing the risk of cross-contamination. Staff also failed to clean and disinfect a meter-dosed inhaler after it was dropped on the floor, which was then placed back into the medication cart without being sanitized. During wound care, a registered nurse did not follow proper hand hygiene protocols, failing to wash hands between handling different wounds on the same resident. The nurse also did not use a clean barrier on the treatment cart, placing supplies directly on potentially contaminated surfaces. This lack of adherence to aseptic techniques during wound care procedures further compromised infection control standards. The facility also did not maintain proper urinary catheter care. Observations showed that urinary catheter bags were left on the floor, which is a known risk for infection. Staff did not change the catheter tubing or bag after it had been on the floor, contrary to the facility's infection control policies. Interviews with staff and the Director of Nursing confirmed that these practices were not in line with the expected standards for infection prevention and control.
Improper Storage and Handling of Oxygen Equipment
Penalty
Summary
The facility failed to ensure a safe physical environment for four residents who were reviewed for respiratory services. During observations, it was noted that oxygen concentrator units and portable oxygen tanks were improperly stored and not in use, despite being present in the residents' rooms. For instance, a portable oxygen concentrator unit was found resting against the right side of a resident's bed, with the nasal cannula tubing coiled up on the floor under the bed. The resident, who is blind and a fall risk, confirmed that they do not use oxygen, and there were no physician orders for oxygen therapy in their records. Similar issues were observed with other residents, where oxygen equipment was found in their rooms without any current orders for oxygen therapy, posing potential safety hazards due to improper storage and handling of the equipment. In another instance, a green cylinder oxygen tank was found standing against the wall in a shared bathroom, which is not a secure storage location. The resident's physician order indicated the use of oxygen as needed for shortness of breath, but the storage of the tank in the bathroom was not in compliance with safety guidelines. The Director of Nursing (DON) acknowledged that oxygen tanks should be stored securely and was unsure why the tank was in the bathroom. Additionally, an oxygen concentrator with tubing labeled with a resident's name was observed sitting on the floor next to the resident's bed, with the nasal cannula and tubing wrapped around the bed rail. The resident mentioned that they do not need to use oxygen all the time, and there were no current physician orders for oxygen therapy. The DON confirmed that the oxygen equipment had been discontinued and subsequently removed from the room. The facility's policy on the safe handling, storage, and transporting of compressed gases was not adhered to, as evidenced by the improper storage of oxygen equipment in residents' rooms and shared spaces.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure privacy for a resident during wound care. During an observation, a Registered Nurse (RN) entered a resident's room without closing the door or blinds, exposing the resident to potential visibility from staff members in the parking lot. Additionally, another staff member interrupted the wound care to thank the resident for cupcakes, further compromising privacy. The RN acknowledged the oversight, and the Director of Nursing confirmed that staff should ensure privacy during care. The facility's policy mandates respect, dignity, and privacy for residents, which was not upheld in this instance.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment in the 300 Hall and the main dining room. Observations revealed black lines along the lower wall of the 300 Hall, and wallpaper outside a resident's room was rippled and peeling away. The Maintenance Director attributed the black marks to residents' wheelchairs and stated that the wallpaper was old and needed replacement. The facility's policy on cleaning and disinfection, last reviewed on 1/15/2024, mandates regular cleaning and disinfection of environmental surfaces, which was not adhered to in this case. In the main dining room, a rolled-up bed linen with a brown stain and dried flaky liquid was found on the floor. The Administrator confirmed the linen's presence but was unaware of its purpose. Additionally, three square floor tiles were missing around the drain in the 100 and 200 hall shower rooms. The Maintenance Director confirmed the missing tiles but stated he was not informed about it. These observations indicate a failure to maintain a clean and homelike environment as required by the facility's policies.
Failure to Conduct New PASARR for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a newly evident serious mental disorder was referred for assessment. Resident #23, who was originally admitted with diagnoses including major depressive disorder and anxiety disorder, was later diagnosed with paranoid schizophrenia on 3/2/2023. However, the resident's Level I PASARR completed on 2/11/2020 did not indicate a diagnosis of schizophrenia, and no new Level I PASARR was conducted after the new diagnosis. The Social Services Director confirmed that a new Level I screening should have been conducted, and the Director of Nursing stated that the facility did not have a policy on PASARR and followed the Resident Assessment Instrument (RAI).
Failure to Develop Person-Centered Care Plan for Epilepsy
Penalty
Summary
The facility failed to ensure a person-centered care plan was developed for the management of epilepsy for a resident. The resident, who was admitted with multiple diagnoses including epilepsy, did not have a care plan that addressed their seizure disorder. Despite having physician orders for Divalproex Sodium to manage epilepsy, the resident's care plan lacked any focus or intervention for this condition. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident's care plan should have included provisions for seizures. The facility's policy and procedures for Plans of Care, last reviewed in January 2024, mandate that an individual person-centered plan of care be established and updated to meet the resident's medical, nursing, mental, and psychosocial needs. However, the review of the resident's care plan revealed non-compliance with this policy, as it did not include measurable objectives and timetables for managing the resident's epilepsy. This deficiency was identified during a record review and interview process, highlighting a significant gap in the resident's care management.
Failure to Change PICC Line Dressing as Per Policy
Penalty
Summary
The facility failed to ensure that Resident #47 received care in accordance with professional standards of practice. Resident #47, who was admitted with multiple diagnoses including paraplegia, chronic respiratory failure with hypoxia, cellulitis of the right lower limb, acute kidney failure, and metabolic encephalopathy, had a peripherally inserted central catheter (PICC) line. Observations on two separate days revealed that the PICC line dressing was dated 4/26/2024, indicating it had not been changed for over 10 days, despite the facility's policy requiring dressing changes every 5 to 7 days or if the dressing becomes damp, loosened, or visibly soiled. The Director of Nursing confirmed that the dressing should have been changed weekly, as per the facility's policy and procedure revised in 11/2023, which aims to minimize catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Additionally, the review of Resident #47's physician orders indicated that the PICC line site should be evaluated for leakage, bleeding, or signs of infection every shift, and the PICC line should be flushed with normal saline every shift, before and after IV medication administration, and as needed twice a day. The failure to adhere to these orders and the facility's own policy resulted in a deficiency in providing appropriate treatment and care according to professional standards of practice for Resident #47.
Failure to Document Post-Dialysis Vitals for Resident
Penalty
Summary
The facility failed to ensure that Resident #42, who required dialysis services, received treatment and care in accordance with professional standards of practice. The physician's order for Resident #42 mandated that a dialysis communication form be completed by the nurse prior to and upon the resident's return from the dialysis clinic. However, multiple reviews of the dialysis communication forms dated between 4/13/2024 and 5/7/2024 showed that no vitals, including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon the resident's return from dialysis. This lack of documentation was confirmed during interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged that the forms were expected to be filled out but were not completed as required. Resident #42's care plan indicated a need for hemodialysis due to renal failure, highlighting the importance of accurate and timely documentation of the resident's condition post-dialysis. Despite the facility's policy and procedures, which required the provision of necessary information for the care of the resident to the dialysis center, the staff failed to adhere to these guidelines. This deficiency in documentation and communication could potentially impact the quality of care provided to the resident, as critical health parameters were not monitored and recorded as stipulated by the physician's orders and facility policies.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure nurse staffing data was posted on a daily basis. During an initial tour, it was observed that the nurse staffing information posted was dated 5/3/2024, despite the tour occurring on 5/6/2024. The Administrator explained that the sheets were filled out but the new receptionist did not know they were behind the one dated 5/3/2024. The Staff Coordinator, who was on vacation, usually updates the staffing information between 8:30 AM and 9:00 AM. Upon returning from vacation, the Staff Coordinator confirmed that the sheets were filled out but not posted correctly due to the new receptionist's unfamiliarity with the process. There was no written policy in place, and the facility followed federal guidelines for posting nurse staffing data.
Failure to Properly Label and Store Food Items
Penalty
Summary
The facility failed to ensure food items were stored in accordance with professional standards for food safety. During an observation of the nourishment room on the rehabilitation wing, conducted with the Certified Dietary Manager (CDM), it was found that there were opened boxes of various cereals and a container of ice cream stored without labels indicating the open date or resident name. The CDM confirmed that these items were not labeled as required. The facility's policy on safe handling of foods from visitors, revised in February 2023 and reviewed in January 2024, mandates that food items intended for later consumption must be labeled with the resident's name and the current date. This policy was not followed, leading to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 10 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Montgomery Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Lake City Healthcare And Rehabilitation Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lake City | 1.4 mi | ★★★★★ | 0 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 21.4 mi | ★★★★★ | 1 | 0 |
| Surrey Place Nursing Center | 22 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.