Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Blue Lake Post Acute during CMS and state inspections, most recent first.
Failure to designate a full-time DON occurred when the DON resigned and the position remained vacant for months, with staff unsure who was formally overseeing nursing services. Interviews showed a sister-facility DON was informally overseeing things, while others coordinated care with an LPN unit manager and another LPN. The consultant pharmacist sent MRRs to the LPN unit manager because she believed that person was filling in as interim DON, but no formal DON designation was identified.
Posted nurse staffing information was not current for public viewing. An observation at the reception desk showed staffing information displaying an outdated date, with no evidence that updated information was available for residents, visitors, or the public. The Scheduler stated she was the only person responsible for posting daily staffing hours and sometimes completed staffing sheets in advance for days she was not present, while the Administrator said he was training her on the posting duties.
Infection prevention and control deficiencies were identified involving an absent water management program, expired ABHS dispensers, exposed enteral feeding tubing for a resident with a G-tube for continuous feeds, and a resident with a Foley catheter whose drainage bag was repeatedly observed resting on the floor. Interviews with the Administrator, IP, housekeeping supervisor, LPN, CNA, and DON showed the facility lacked documentation for the water management program, did not monitor ABHS expiration dates, left tube feeding tubing uncapped when not in use, and allowed catheter drainage bags to remain on the floor despite policy requiring them to stay off the floor.
Late Completion of Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments on time for multiple residents. An LPN/MDS Coordinator confirmed several assessments were overdue and incomplete, stated she was trying to catch up, and reported she did not have readily available RAI Manual instructions or a facility policy for MDS completion or transmission.
The facility failed to review and act on consultant pharmacist medication regimen review irregularities. A resident had duplicate Vitamin D orders, excessive zinc dosing, and a PRN Ativan order that were not addressed; another resident had multiple psychotropic medications flagged for dose review and possible GDR; a third resident’s alendronate was scheduled at an inappropriate time and staff were unaware of the administration requirements; and a resident with severe cognitive impairment had psychotropic GDR recommendations and ongoing Depakote use that were not documented as reviewed or justified. The DON stated the monthly MRR reports for several months had not been reviewed by staff or practitioners.
A resident’s indwelling urinary catheter drainage bag was left uncovered and visible from the door on repeated observations, with clear yellow urine seen in the bag while the resident lay in bed and was unable to be interviewed. A visitor stated the resident would not like the bag exposed, and staff, including a CNA and the DON, stated catheter drainage bags should be covered to maintain privacy and dignity. The resident had dx including neuromuscular dysfunction of the bladder, dementia, and need for assistance with personal care, and the care plan directed the bag and tubing to be positioned below the bladder and away from the door.
Failure to Assess Residents for Safe Self-Administration of Bedside Medications: Two cognitively intact residents had medications left at the bedside without documented self-administration assessments or orders. An LPN found Simethicone in a cup on one resident’s bedside table and two bottles of fluticasone nasal spray on another resident’s bedside table; the DON stated residents would need an assessment and physician order before self-administering meds, and the facility had no residents self-administering medications.
Dusty Fan in Resident Room: A resident room fan was observed turned on and in motion with a thick layer of grey dust on the back grate while multiple residents were in the room. One resident questioned whether he was breathing in the dust. Housekeeping staff gave conflicting responses about who cleaned fan backs, and the HM stated he cleaned oscillating fans every two weeks but had no documentation showing when the fan had last been cleaned. The facility policy required daily room cleaning and maintained cleaning logs.
A resident with CVA and left hemiparesis did not receive ordered splinting/restorative care because his left-hand brace/palm guard was missing and had not been applied for months. The resident was observed in bed without the device, stated staff had not been putting it on, and therapy and nursing staff reported the brace had gone missing and was not being tracked after therapy discharge. The record included orders for PROM and staff assistance with the left-hand splint, along with care plan interventions for splinting and a nursing rehab palm guard program.
An LPN administered multiple once-daily meds to a resident well before the scheduled 9:00 a.m. time, then stated she could not document them yet on the eMAR and that she gave them early because that was how she was trained. The DON confirmed the meds should have been given within the 8:00 a.m. to 10:00 a.m. window, and the facility’s med administration policy required meds to be given at the right time.
Unlocked Medication Refrigerator and Controlled Drug Storage Deficiency: A small medication refrigerator in the nurses' station area was observed unlocked even though it contained refrigerated meds, and an LPN/Unit Manager confirmed it held insulin, inhalers, and a labeled box of liquid lorazepam for a resident. The lorazepam was kept in a locked inner box, but the outer refrigerator was not secured, and both the DON and Consultant Pharmacist confirmed the refrigerator should have been locked and controlled substances double-locked.
Eight residents were found to have long, thick, and discolored toenails, with several reporting pain and discomfort, and none had current or past podiatry care orders. Staff interviews revealed unfamiliarity with nail care policies, lack of documentation, and delays in arranging podiatry services, resulting in residents not receiving necessary foot care.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment. Despite known behavioral issues and previous orders for increased monitoring, staff failed to provide adequate supervision, resulting in inappropriate sexual contact. Care plans and interventions were not updated promptly, and administrative follow-up was delayed, leaving the resident and others at risk.
A female resident with severe cognitive impairment and behavioral issues was found in another resident's bed with her pants unbuttoned, while a male resident stood beside her with his hand inside her pants. Staff failed to maintain adequate supervision despite escalating inappropriate interactions. The facility's investigation was incomplete and inconsistent, with missing or inaccurate witness statements and a lack of timely interviews. Care plans and monitoring orders were not promptly updated or implemented for either resident following the incident.
Facility staff failed to provide appropriate supervision and implement necessary interventions to protect a cognitively impaired resident from sexual abuse by another resident. Despite clear behavioral warning signs and physician orders for increased monitoring, staff left the residents unsupervised, resulting in an incident of inappropriate sexual contact. Documentation and investigation of the event were inconsistent, and the administration did not ensure protective measures were in place.
A QAA committee failed to develop and implement effective corrective actions after an incident where a female resident with severe cognitive impairment and behavioral issues was found in a male resident's bed with evidence of inappropriate sexual contact. Staff observed escalating inappropriate interactions but did not maintain adequate supervision, and the facility did not promptly update care plans or communicate with the Medical Director. The QAPI process was not followed as required by facility policy.
The facility did not promptly report allegations of abuse and the results of related investigations to the State Survey Agency as required. In one case, a resident with multiple health issues experienced rough treatment by a CNA, which was not immediately reported as abuse. In another case, two residents were involved in inappropriate sexual behavior, but the incident was not reported within the required timeframe. The facility's actions did not align with its own policy or federal reporting requirements.
The facility failed to prevent contamination of refrigerated food due to an unclean evaporator fan in the walk-in refrigerator. Observations revealed a build-up of dust-like debris on the fan, which was not cleaned over several days. This resulted in a tray of sandwiches being exposed to potential contamination after the plastic wrap was blown off by the fan. The certified dietary manager confirmed the issue and identified the Maintenance Department as responsible for cleaning the fan.
The facility failed to provide documentation for its QAPI program during a review with the Administrator and DON. Despite claims of monthly meetings and performance improvement plans, no evidence was available. The only document provided was an outdated sign-in sheet, and the facility's QAPI policy was not presented.
A facility failed to complete and submit MDS assessments for several residents within the required timeframes. An LPN responsible for these tasks was unaware of the overdue assessments until informed during a survey. The residents affected had complex medical conditions, and the deficiency persisted despite the LPN's efforts to manage the workload.
The facility failed to complete quarterly MDS assessments for four residents, as identified during a review of records and staff interviews. An LPN responsible for assisting with these assessments was unaware of the overdue status until informed, acknowledging the late submissions. The assessments were not completed in a timely manner, affecting the comprehensive evaluation of residents' needs and goals.
A facility failed to notify a resident and her representative in writing about an emergency hospital transfer, and did not inform the LTCO. The resident, with a history of mental health issues, exhibited aggressive behavior leading to an involuntary psychiatric admission. The facility did not provide the required AHCA Transfer/Discharge Notice or notify the LTCO, as confirmed by the Social Services Director.
A facility failed to provide a resident and/or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with multiple mental health diagnoses, was involuntarily admitted to a psychiatric unit due to aggressive behavior. The facility did not document any written notice about the bed-hold policy, as confirmed by the SSD.
The facility failed to refer residents with newly diagnosed serious mental illnesses for PASRR Level II screenings, affecting three residents. A resident with schizoaffective disorder and other mental health diagnoses, another with major depressive disorder and generalized anxiety disorder, and a third with generalized anxiety disorder were not referred for necessary screenings. The Social Services Director noted the absence of a system to review Level I screenings for necessary Level II referrals, despite facility policy requiring such actions upon significant changes in mental health status.
A resident with severe cognitive impairment was found unsupervised, trimming her own toenails despite having a history of onychomycosis and associated pain. The facility lacked an assessment of her ability to safely perform nail care and had no policy on residents' use of nail clippers. Staff were unaware of the resident's possession of clippers and the podiatrist's findings, leading to inadequate supervision and risk of injury.
The facility failed to implement effective infection control practices, as two residents were observed without enhanced barrier precautions (EBP) signage. One resident with a urinary catheter had the collection bag and tubing touching the floor, while another with an enteral feeding tube also lacked EBP signage. Staff interviews revealed inconsistencies in training and communication regarding EBP, highlighting a gap in the facility's infection prevention policy implementation.
Failure to Designate a Full-Time DON
Penalty
Summary
The facility failed to designate a full-time Director of Nursing (DON) after the DON resigned effective immediately on 1/18/26, leaving the position vacant from 1/19/26 through 4/5/26. During the entrance conference on 4/6/26, the Administrator identified the current DON and stated that it was her first day back, confirming she had resigned in January 2026 and returned on 4/6/26. The DON later stated she did not know who had been designated during the period she was gone, and the Administrator stated he was not sure whether anyone had been designated as DON during that time. Additional interviews showed staff were unsure who was overseeing nursing leadership during the vacancy. The Rehabilitation Director stated he did not know who the DON was during that period and reported concerns to Unit Manager LPN D. The Regional RN Consultant stated the DON at a sister facility had been overseeing things, but confirmed that person had not been formally designated as DON for this facility. The Consultant Pharmacist said she sent March 2026 medication regimen review reports to LPN D because she believed LPN D had been filling in as interim DON, and the APRN stated she coordinated resident care with LPN/Unit Manager D and LPN H during that time. The DON job description stated the DON was responsible for overall leadership, direction, and management of nursing services, including clinical oversight, staff supervision, regulatory compliance, and coordination of resident care.
Posted Nurse Staffing Information Was Not Current
Penalty
Summary
The facility failed to ensure that nurse staffing information posted for public viewing was current. On 4/9/2026 at 9:31 AM, an observation at the reception desk showed that the posted nurse staffing information reflected a date of 4/1/2026, and there was no evidence that updated staffing information for the day of observation was available for residents, visitors, or the public to review. During an interview on 4/09/2026 at 10:56 AM, the Scheduler stated she was the only individual responsible for posting daily staffing hours and that she attempted to complete staffing sheets in advance for days she was not present, typically on weekends. In a separate interview on 4/10/2026 at 2:02 PM, the Administrator stated he was in the process of training the Scheduler to perform the staffing posting duties. A review of the Scheduler's job description dated 12/18/2025 showed that she was responsible for creating and maintaining accurate staffing schedules for nursing and other facility departments to ensure adequate coverage.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to provide evidence of an ongoing water management program for the entire facility. The Infection Preventionist and the Unit Manager-in-training identified the Administrator as responsible for oversight of the water management program. The Administrator stated he had only been in the position for a few weeks and said the program had been maintained by the previous Maintenance Director through a contracted service. He further stated the facility did not have documentation of the water management program because it was believed to have been taken by the former Maintenance Director, and the Regional Nurse said they were trying to contact the water management company to retrieve evidence of the program. At a later interview, the Administrator and Regional Nurse were unable to provide evidence of the water management program. The facility also had expired alcohol-based hand sanitizer dispensers on multiple wings. Observation of dispensers in resident rooms and in a hallway showed expiration dates of 2026/03/25. The Infection Preventionist stated the housekeeping supervisor was responsible for changing the dispensers throughout the facility. The housekeeping supervisor said he checked dispensers during maintenance rounds but did not have a set routine for replacement and did not monitor expiration dates. He also stated he did not keep track of usage or replacement timeframes based on expiration dates. A total of 27 ABHS dispensers were counted in the facility, and one hallway dispenser had an expiration date that was not visible until the bottle was removed from the dispenser. Resident #9, who had a gastrostomy tube for continuous enteral feeding related to dysphagia and late effect CVA, was observed with the end of the feeding tubing hanging over a pole and exposed to air without a cap or cover when not in use. The LPN stated she did not think the end was intended to be left open and that there should probably be a cap for it. Resident #5, who had diagnoses including benign prostatic hyperplasia and flaccid neuropathic bladder and a BIMS score of 6, was repeatedly observed with the urinary catheter drainage bag resting on the floor. The bag was seen on the floor during multiple observations while the resident was in bed and while awake and eating lunch. Staff interviews confirmed that catheter drainage bags should not rest on the floor, and the facility policy required catheter tubing and drainage bags to be kept off the floor.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed at least every three months for six residents whose records were reviewed. Resident #8’s quarterly MDS was due on 2/18/26, Resident #38’s was due on 2/14/26, and Resident #52’s was due on 2/21/26, but there was no evidence these assessments had been completed by the time of the recertification survey conducted from 4/6/26 through 4/10/26. Resident #59’s last quarterly MDS was completed on 12/3/25, and the next quarterly assessment was due by 3/5/26; as of 4/9/26, it was 21 days overdue. During interview, the LPN/MDS Coordinator stated she had been working as the MDS Coordinator for both this facility and a sister facility for about two years and reported that assessments were already behind when she assumed the role. She stated another nurse had been trained at the sister facility but left after nine months, which returned both buildings’ MDS responsibilities to her around January 2026. She confirmed that the quarterly MDS assessments for Residents #7, #8, #38, #45, #52, and #59 were late and had not been completed. She also stated she could not locate the RAI Manual instructions for timing, completion, and encoding of MDS assessments and did not have a facility policy regarding MDS completion or transmission. The record also showed Resident #7’s quarterly MDS with an ARD of 2/16/26 remained incomplete as of 4/9/26, and Resident #45’s quarterly MDS with an ARD of 3/4/36 remained incomplete as of 4/9/26, exceeding the required ARD plus 14-day completion timeframe.
Unaddressed Consultant Pharmacist Medication Review Irregularities
Penalty
Summary
The facility failed to ensure that monthly consultant pharmacist drug regimen review irregularities were reviewed and acted upon by the attending physician, Medical Director, or DON. The DON stated that the January, February, and March 2026 medication regimen review reports were not in the facility prior to 4/8/26 and had not been reviewed by any staff member or practitioner. She also stated the facility did not have a policy regarding Medication Regimen Review, and that recommendations were typically reviewed within one week of receipt based on her prior experience. For Resident #5, the consultant pharmacist identified multiple irregularities in the medication regimen review, including two active Vitamin D orders with one dose of 50,000 units daily and another of 5,000 units daily, excessive zinc dosing, and the need to evaluate continued use of PRN Ativan 0.5 mg for anxiety. A later review again identified the duplicate Vitamin D orders and the zinc issue, and again requested evaluation and discontinuation of the 50,000-unit Vitamin D dose. The record did not show that these irregularities had been reviewed or acted upon. For Resident #38, the pharmacist identified psychotropic medication concerns involving Zoloft 75 mg daily, Trazodone 100 mg at bedtime, Xanax 1 mg at bedtime, and Buspar 10 mg three times daily, and requested evaluation of the doses and consideration of a gradual dose reduction with documentation of the clinical rationale. For Resident #6, the pharmacist noted that Alendronate 70 mg weekly was scheduled for 9:00 a.m. and requested clarification because bisphosphonates should be given in the morning before food or other medications and with the resident remaining upright afterward; staff later confirmed it was being given after breakfast and without awareness of the pharmacy recommendation. For Resident #2, who had cerebral atherosclerosis, unspecified dementia with agitation, and a BIMS score of 3, the pharmacist recommended a gradual dose reduction of Olanzapine and noted that Depakote 500 mg three times daily had still not been addressed, with no documented evidence of implementation, clinical justification, or monitoring for continued use.
Uncovered urinary catheter bag exposed resident dignity
Penalty
Summary
The facility failed to ensure care was provided in a manner that maintained resident dignity when one resident’s indwelling urinary catheter drainage bag was left uncovered. On 04/06/2026, the resident was observed lying in bed with a visitor present, and the Foley drainage bag was on the right side of the bed, facing the door, with clear yellow urine visible in the collection bag. The resident was unable to be interviewed, and the visitor stated she did not think the resident would like the bag exposed because staff and visitors were in and out of the room and able to see it. On 04/07/2026, the resident was again observed lying in bed and did not respond when her name was called, and the urinary catheter drainage bag was again observed uncovered with clear yellow urine visible. The resident had diagnoses including neuromuscular dysfunction of the bladder, need for assistance with personal care, and dementia. The care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the door, and the physician’s orders included draining the suprapubic catheter bag every shift and providing catheter care daily and as needed. Staff interviews reflected that catheter drainage bags should be covered to maintain privacy and dignity, and the DON stated that was the facility’s expectation.
Failure to Assess Residents for Safe Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to ensure residents were assessed for safe self-administration of medications when medications were left at the bedside for two residents. For Resident #59, a white round tablet was observed in a clear medication cup on the bedside table, and the resident stated the nurse must have left it for him to take the prior night. Resident #59 had been admitted to the facility and was cognitively intact, with a BIMS score of 15 out of 15, but the record showed no indication that he had been reviewed for the ability to self-administer medications left at the bedside. The pill was identified by an LPN as Simethicone, an over-the-counter medication ordered three times daily, and the MAR showed it had been documented as given for all three doses the previous day. For Resident #55, who had diagnoses including encephalopathy and acute and chronic respiratory failure with hypercapnia, two bottles of Fluticasone Propionate nasal spray were observed in a bin on the bedside table. The resident stated he used the nasal spray daily for stuffiness, and the resident's MDS admission assessment showed a BIMS score of 15 out of 15. The LPN acknowledged the nasal spray but found no physician's order for it, and stated there was no order for the resident to self-administer medication. The facility policy stated that if a resident or family member desires self-administration, a licensed nurse conducts an assessment of the individual's cognitive, physical, and visual ability, and the DON stated residents would be assessed first and would have a physician's order to self-administer medications; she also stated the facility had no residents who self-administered medication and medications should not be left at the bedside for residents to self-administer.
Dusty Fan in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment when an oscillating floor fan in a resident room was observed with a thick layer of grey dust on the back grate while it was turned on and in motion. On 04/07/2026, Resident #38 was lying in bed in the room with the fan positioned past the foot of the bed between his bed and Resident #5's bed, and Residents #18, #5, and #54 were also present in their beds. During the observation, Resident #38 asked whether the fan was caked in dust and stated, "Am I breathing that in?" Photographic evidence was obtained. The same fan was observed again on 04/08/2026, still turned on and in motion with a thick layer of grey dust on the back grate while Residents #18, #5, and #54 were in the room. Two housekeepers were cleaning at the time. Housekeeper E stated she did not clean the backs of fans and that the Housekeeping Director would do that, while Housekeeper M stated he did not know who cleaned the backs of the fans. The Housekeeping Manager stated he was responsible for cleaning oscillating fans and cleaned them every two weeks, and he acknowledged seeing the dust on the fan. He provided a Housekeeping Daily Cleaning Schedule dated 3/25/26, but it did not reference a resident-specific room or area and did not specify fan cleaning or dusting tasks. He stated he had no other documentation showing when fans were cleaned. The facility policy stated Environmental Services is responsible for cleaning, disinfection, and sanitation, daily cleaning of resident rooms is required, and cleaning logs are to be maintained and available for survey review.
Missing Left-Hand Brace Not Applied as Ordered
Penalty
Summary
The facility failed to ensure that a resident with CVA and left hemiparesis received ordered restorative and splinting care when a physician-ordered left-hand brace/palm guard was not available and had not been applied as ordered. The resident was observed in bed on multiple occasions with left-sided upper and lower extremity deficits, and no brace or splint was in place. He stated he had used to have a brace for his left hand, but it had been missing for months and that staff had not been applying it. The resident’s record showed orders for PROM to the left arm and for staff to assist with application of a left-hand splint, remove it after two hours, and assess skin before and after use. The care plan also included a splinting program for the left upper extremity and a nursing rehabilitation program to apply a palm guard to the left hand for six hours daily. The most recent OT evaluation documented goals for the resident to safely wear the palm guard and for restorative nursing staff to demonstrate accuracy in donning and doffing the left palm guard and completing daily hygiene and skin checks. During interviews, therapy staff stated the resident had previously had a splint during therapy, but it went missing, and the left palmar hand guard had been ordered multiple times but also went missing. Therapy staff stated they did not track the item after discharge from therapy and believed it may have been lost or discarded with laundry. Nursing staff interviewed stated they had not seen the brace, and the DON stated she was not aware of the order and that documentation showed the brace was applied on some days and marked not applicable on others.
Medication Administration Timing Errors
Penalty
Summary
The facility failed to ensure its medication error rate was not 5% or greater. Surveyors calculated a medication error rate of 36%, based on 11 medication errors observed out of 30 opportunities for error. During observation on 04/07/2026 at 6:15 a.m., an LPN prepared multiple once-daily medications for Resident #16, including Allopurinol 100 mg, Aspirin 81 mg, Citalopram 20 mg, Cranberry Tablet 450 mg, Folic Acid 1 mg, Furosemide 20 mg, Gemtesa 75 mg, Losartan Potassium 50 mg, Metformin 500 mg, Metoprolol Succinate ER 25 mg, and Nitrofurantoin Macrocrystal 50 mg. At 6:18 a.m., the LPN entered the resident’s room, where the lights were off and the resident was lying in bed with eyes closed and covers pulled up. After calling the resident’s name twice, the resident opened his eyes, sat up, and received the medications, then lay back down and closed his eyes. When asked about documentation, the LPN stated she could not sign the medications as given because they would not appear on the eMAR for another half hour and said the medications were ordered for 9:00 a.m. She explained she administered them early because that was how she was trained and because she had started work early that day. The DON later stated that daily medications scheduled for 9:00 a.m. could be given only within one hour before or after the scheduled time, and that 9:00 a.m. medications should be administered between 8:00 a.m. and 10:00 a.m. The facility’s Medication Times document listed everyday medications at 9:00 a.m., and the medication administration policy required medications to be given according to the right medication, right resident, right time, and right dose and route.
Unlocked Medication Refrigerator and Inadequately Secured Controlled Substance
Penalty
Summary
The facility failed to ensure refrigerated medications were stored in a locked compartment and failed to ensure Schedule II-V controlled medications were secured within a fully protected, double-locked system. On 04/09/2026 at 8:40 a.m., a small refrigerator was observed in the open and unsecured nurses' station area. Although it had a white lock on the front, the lock was not engaged, and the surveyor was able to open the refrigerator without staff assistance or intervention. During an interview later that morning, an LPN/Unit Manager stated the refrigerator contained insulin and inhalers requiring refrigeration and that a labeled box of liquid Lorazepam for one resident was stored in the locked box inside the refrigerator. She retrieved a key from the DON's office to open the box and confirmed the refrigerator was unlocked and should have been locked. The DON later confirmed the refrigerator should be locked at all times, and the Consultant Pharmacist confirmed the refrigerator should be locked at all times and controlled substances should be double-locked in a permanently affixed compartment. The facility policy stated medications and biologicals were to be stored in locked compartments, refrigerated medications were to be stored in a secured location, and Schedule II-V controlled substances were to be separately locked in permanently affixed compartments.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide foot care consistent with professional standards of practice for eight residents reviewed. Multiple residents were observed to have very long, thick, and discolored toenails, with some residents reporting pain and discomfort. Interviews with residents and their family members revealed that they had not seen a podiatrist, and photographic evidence was obtained to document the condition of their toenails. Review of medical records and physician's orders for these residents showed no current, past, or discontinued orders for podiatry care, visits, or referrals, except for one resident who had a single podiatry note with no ongoing documentation of foot or toenail care. Staff interviews indicated a lack of familiarity with the facility's nail care policy and procedure. The unit manager stated that while feet are assessed for skin issues, toenail conditions are not documented, and residents with long or damaged toenails are placed on a list for podiatrist visits, which are coordinated by social services. Certified Nursing Assistants reported that they do not cut residents' nails and would report long nails to a nurse. The Social Services Director explained that previous podiatry services required cash payment and that a new contract with a podiatrist had recently been established, but services had not yet started. The appointment book for podiatry visits could not be located when requested. The Director of Nursing confirmed that a new podiatrist had been contracted but was unaware of a start date and was not familiar with the nail care procedure. Overall, the facility did not ensure that residents received necessary foot care or assistance in making appointments with qualified healthcare providers, resulting in multiple residents experiencing prolonged periods without appropriate podiatry care.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident with moderate cognitive impairment. The resident who was unable to consent to sexual activity had a history of aggressive behaviors, severe cognitive deficits, and required significant assistance with personal care. Despite documented behavioral issues and a care plan noting inappropriate sexual advances, the facility did not implement or maintain adequate supervision or interventions to prevent inappropriate contact between the two residents. On the day of the incident, staff observed escalating physical interactions between the two residents, including hand-holding and attempts at physical closeness, but only provided verbal redirection and did not increase supervision. Both residents were left unsupervised for a period, during which time staff later found the resident with severe cognitive impairment in the other resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Documentation revealed that orders for increased monitoring had been discontinued prior to the incident, and there was no evidence of frequent or one-on-one supervision in place at the time of the event. Following the incident, it was noted that care plans and interventions for both residents were not updated in a timely manner to address the risk of further inappropriate contact. The facility's policies required immediate intervention and protection in cases of suspected abuse, but staff interviews and record reviews indicated that administrative follow-up and investigation were delayed. The lack of prompt and effective interventions created an ongoing risk for abuse of the resident and potentially other vulnerable residents.
Failure to Investigate Sexual Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, resulting in a deficiency cited at Immediate Jeopardy level. The incident involved a female resident with severe cognitive impairment, behavioral disturbances, and a history of aggression and wandering, and a male resident with moderate cognitive impairment and no prior behavioral issues. On the day of the incident, staff observed escalating inappropriate interactions between the two residents, including physical contact and attempts to sit together, but did not maintain adequate supervision. Eventually, both residents were found in the male resident's room, with the female resident lying on the bed with her pants unbuttoned and the male resident standing beside her with his hand inside her pants. Both LPNs present at the scene confirmed witnessing this event. The facility's investigation into the incident was incomplete and inconsistent. The Administrator initially failed to obtain statements from all involved staff, provided conflicting information about witness identities, and did not interview the male resident involved. There were discrepancies in the documentation and staff schedules, and the Administrator relied on statements that were later found to be inaccurate or attributed to the wrong individuals. The investigation was not promptly or thoroughly conducted, as required by the facility's own abuse policy, and the Administrator only substantiated the abuse allegation after being confronted with new information from staff interviews days after the incident. Additionally, the facility did not implement or document appropriate supervision or care plan interventions for either resident immediately following the incident. Orders for increased monitoring were either discontinued or not implemented, and care plans were not updated in a timely manner to address the behavioral risks. The lack of a prompt, thorough investigation and failure to ensure resident safety and supervision contributed to the deficiency cited by surveyors.
Failure to Supervise and Protect Resident from Sexual Abuse
Penalty
Summary
Facility administration failed to ensure appropriate supervision and protection of a vulnerable resident from sexual abuse. One resident with severe cognitive impairment, aggressive behaviors, and a history of wandering and inappropriate actions was not provided with consistent monitoring as ordered by physicians. Orders for 1:1 and 30-minute monitoring were inconsistently implemented and, at times, discontinued without documentation of increased or frequent monitoring, leaving the resident unsupervised for extended periods. On the day of the incident, staff observed escalating interactions between two residents, including physical contact and attempts at inappropriate proximity. Despite these warning signs, staff left the area to attend to other duties, resulting in both residents being unsupervised. When staff returned, they found the cognitively impaired resident in another resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Both residents were fully clothed, but the situation indicated inappropriate sexual contact had occurred without adequate supervision or intervention. Interviews and record reviews revealed confusion and inconsistencies in staff documentation, witness statements, and the facility's investigation process. The administration did not ensure that interventions for increased supervision were implemented for either resident following the incident, and there was a lack of clear communication and follow-through regarding abuse investigation and reporting. The failure to provide necessary supervision and to implement protective interventions created a situation of immediate jeopardy for vulnerable residents.
Failure of QAA Committee to Address and Correct Quality Deficiencies Leading to Resident Sexual Abuse
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that resulted in adverse outcomes. This failure was evident in the lack of improvement in systems and processes, which contributed to an incident of sexual abuse involving a female resident with severe cognitive impairment and a male resident. The QAA did not initiate or follow through with performance improvement projects or ad hoc QAPI meetings after the incident, and the Medical Director was not promptly informed of the event or the transfer of the involved male resident. The female resident involved had a history of severe cognitive impairment, aggressive behaviors, and required significant assistance with personal care. Her care plan documented behavioral issues, including aggression and inappropriate behaviors, but monitoring orders were inconsistently implemented and discontinued without documentation of increased supervision. On the day of the incident, staff observed escalating inappropriate interactions between the two residents but did not maintain adequate supervision, resulting in the female resident being found in the male resident's bed with evidence of inappropriate sexual contact. The male resident had moderate cognitive impairment and no prior psychiatric diagnoses or behavioral issues documented before the incident. After the event, his care plan was updated to include interventions for hypersexuality, but there was no intervention for increased supervision from the time of the incident until his transfer. Staff interviews revealed that administrative and clinical leadership did not conduct an ad hoc QAPI meeting or ensure timely communication with the Medical Director. The facility's QAPI policy required proactive and comprehensive quality improvement actions, but these were not followed in response to the incident.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to the appropriate officials, including the State Survey Agency. Additionally, the facility did not report the results of the investigations to the State Survey Agency within five working days of the incidents. These failures were identified in three residents reviewed for abuse out of a total survey sample of eight residents. The reporting requirements under this regulation are based on real (clock) time, not business hours. One resident, who had multiple complex medical conditions including acute respiratory failure, congestive heart failure, diabetes, morbid obesity, and moderate cognitive impairment, was involved in an incident where his family alleged that a CNA was rough and rude while assisting him with toileting. The incident was initially reported by the resident to his family, who then reported it to the facility. The facility's Social Services Director completed a grievance form, but the incident was not immediately recognized or reported as abuse. The Administrator initially considered the matter a customer service issue and did not file an abuse report until confronted by the family, resulting in a delay in reporting the allegation to the State Survey Agency. In another incident, two residents were found in a situation involving likely inappropriate sexual behavior. Nursing staff discovered the incident and separated the residents, notifying the Administrator in Training. However, the facility did not submit the required 5-day federal report until several days after the incident, with the Administrator stating that submission within five business days was considered timely according to their practice. The facility's own policy required reporting of abuse allegations within two hours, but this was not followed in these cases.
Refrigerated Food Contamination Risk Due to Unclean Fan
Penalty
Summary
The facility failed to store refrigerated food in a manner that prevents contamination by airborne matter. During an initial tour of the kitchen, the walk-in refrigerator's evaporator fan was observed with a build-up of thick, dark matter resembling dust on the grates of the fan cover. This debris was moving due to the fan blowing cold air around, posing a risk of contamination to exposed food. A subsequent inspection revealed that the fan remained uncleaned, with visible dust-like debris on all surfaces. A tray of sandwiches in the refrigerator was found with its plastic wrap blown off, exposing the food to potential contamination. The certified dietary manager confirmed the soiled condition of the fan and the risk to the uncovered food, stating that the Maintenance Department was responsible for cleaning the fan.
Lack of Documentation for QAPI Program
Penalty
Summary
The facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. During a QAPI review with the Administrator and the Director of Nursing, no current documentation was provided to verify the development, implementation, and maintenance of an effective, comprehensive, data-driven QAPI program. The only document provided was a QAPI Plan Review form dated over two years prior, which was merely a sign-in sheet with staff signatures. Additionally, policy and procedure manuals were presented, but they did not pertain to the QAPI program. The Administrator claimed that monthly QAPI meetings were held and that there were two current performance improvement plans in place, but no documented evidence was available to support these claims. Furthermore, the Administrator mentioned an annual review of facility policies and procedures with the QAPI committee, yet no documentation was provided to verify this review. The facility's QAPI policy was also not provided during the survey.
Deficiency in Timely MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals within the required timeframes for five residents out of a sample of nine whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a survey of 34 residents. The residents affected included those with complex medical conditions such as congestive heart failure, dementia with behavioral disturbances, schizoaffective disorder, encephalitis, encephalomyelitis, hemiplegia/hemiparesis following a cerebral infarction, metabolic encephalopathy, and diffuse traumatic brain injury. The assessments in question were either incomplete or not finalized and electronically submitted, as required. The issue was primarily linked to the actions of an LPN who was responsible for initiating and transmitting the MDS assessments. The LPN had been assisting with these assessments for about 90 days and was unaware of the outstanding or overdue assessments until informed during the survey. Despite acknowledging the overdue assessments, the LPN stated she was doing her best to manage the workload. The Director of Nursing was responsible for reviewing and locking the assessments, but the deficiency persisted, indicating a lapse in the timely completion and submission of the required assessments.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals quarterly for four of nine sampled residents whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a review of resident records and an interview with staff. Specifically, the quarterly Minimum Data Set (QMDS) assessments for Residents #15, #14, #9, and #42 were not completed in a timely manner. Resident #15's QMDS initiated on 5/30/24 was still in progress, Resident #14's QMDS was also incomplete, Resident #9's most recent QMDS was still in progress, and Resident #42's QMDS was not completed. These assessments were initiated by Licensed Practical Nurse (LPN) J. During an interview, LPN J confirmed that she had been assisting with MDS assessments over the last 90 days and acknowledged the late submissions. She stated that once the assessments were done, the Director of Nursing reviewed and locked them, and then she transmitted them electronically. However, she was not aware of any outstanding or overdue assessments until informed of the findings. LPN J admitted to the late submissions and expressed that she was doing her best to help, indicating a lack of awareness and oversight in the timely completion of these assessments.
Failure to Notify Resident and LTCO of Emergency Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and her representative regarding an emergency hospital transfer, as well as failing to notify the Office of the State Long-Term Care Ombudsman (LTCO). The resident, who had a history of type 2 diabetes mellitus, schizoaffective disorder, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and seizure disorder, exhibited aggressive behavior on the day of the incident. She was pacing, yelling, and threatening other residents, which led to her being removed from the area. Despite these actions, she returned and continued to display aggressive behavior. A clinical psychologist completed a Certificate of Professional Initiating Involuntary Examination, noting the resident's refusal for voluntary examination and her potential to cause harm due to her mental illness. Consequently, the resident was admitted to a psychiatric ward with police assistance. However, the facility did not provide an AHCA Transfer/Discharge Notice to the resident or her representative, nor did they inform the LTCO in writing about the transfer. An interview with the Social Services Director confirmed the absence of written notice and notification to the LTCO, indicating a lapse in the facility's protocol for handling such transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the bed-hold policy and the duration for which the bed would be held during the resident's transfer to a hospital. This deficiency was identified during a review of resident records and staff interviews, specifically concerning a resident who was transferred to a psychiatric unit under an involuntary admission. The resident's medical record lacked evidence of any written notice about the bed-hold policy, which is a requirement. The resident involved had multiple diagnoses, including type 2 diabetes mellitus, schizoaffective disorder, dementia, and other mental health conditions. On the day of the incident, the resident exhibited aggressive behavior, threatening other residents and staff, which led to her being transported by police to a psychiatric unit. Despite these events, the facility did not provide the necessary written information about the bed-hold policy to the resident or her representative, as confirmed by the Social Services Director during an interview.
Failure to Refer Residents for PASRR Level II Screening
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses for a Pre-Admission Screening and Resident Review (PASRR) Level II screening, which is necessary to ensure appropriate care and services. This deficiency was identified for three residents out of a sample of 34. Resident #25 had diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder, but was not referred for a Level II screening upon admission or after new diagnoses. Similarly, Resident #40, admitted with major depressive disorder and later diagnosed with generalized anxiety disorder, was not referred for a Level II screening. Resident #47, diagnosed with generalized anxiety disorder, also lacked a Level II screening referral. The Social Services Director (SSD) acknowledged that there was no current system in place to review Level I screenings for new or existing diagnoses that would necessitate a Level II review. The SSD had previously been responsible for monitoring PASRRs and submitting Level II review requests, but this responsibility was shifted to nursing staff without a clear process in place. The facility's policy requires referrals for Level II reviews upon significant changes in residents' mental health status, but this was not adhered to, leading to the deficiency.
Failure to Supervise Resident's Nail Care
Penalty
Summary
The facility failed to identify and minimize the risk of accidents and provide adequate supervision to prevent accidental injury for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including unspecified dementia and schizoaffective disorder, was observed performing her own toenail care unsupervised, despite having a history of onychomycosis and associated pain. The resident's medical record lacked an assessment of her ability to safely perform her own nail care, and there was no facility policy or protocol regarding the use of nail clippers by residents. The resident was seen by a podiatrist who noted the risk of soft tissue damage due to her thickened, elongated toenails. Despite this, the resident was found trimming her toenails with a metal nail clipper without staff supervision. Interviews with staff revealed a lack of awareness regarding the resident's possession of nail clippers and the podiatrist's findings. The Director of Nursing and other staff members were unaware of any policy or protocol for assessing residents' safe use of sharp grooming implements. Staff interviews indicated that the resident was known to reject assistance with activities of daily living, and there was confusion among staff about who was responsible for toenail care. The resident's guardian was informed of the situation, and staff attempted to retrieve the nail clippers from the resident, who refused to relinquish them. The lack of communication and clear protocols contributed to the oversight in the resident's care, leading to the deficiency noted in the report.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions (EBP) for two residents. Resident #38, who was admitted with an indwelling urinary catheter and had a history of urinary tract infections, was observed multiple times with his catheter collection bag and tubing touching the floor, without any EBP signage on his room door. Interviews with staff revealed that while they had received some training on catheter care, there was a lack of consistent implementation of preventive measures, such as ensuring the catheter bag did not touch the floor. Similarly, Resident #22, who had an enteral feeding tube, was observed on several occasions without EBP signage on his room door. Staff interviews indicated confusion about how they were informed of residents requiring EBP, with reliance on electronic records and shift change reports rather than visible signage. The Infection Preventionist/Director of Nursing confirmed that signage should be present to alert staff and visitors of necessary precautions. The facility's infection prevention and control policy aimed to prevent the transmission of infections and manage nosocomial infections, but the observed deficiencies highlighted a gap in the implementation of these policies. The lack of EBP signage and improper catheter care practices for the sampled residents demonstrated a failure to adhere to the facility's stated procedures, potentially increasing the risk of infection transmission.
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What surveyors actually found near you
We read the 164 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.
Illustrative
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 Deland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Palms Health And Rehabilitation Center Of Del | 0.5 mi | ★★★★★ | 0 | 0 |
| Parkside Health And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Alliance Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Athens Post Acute Llc | 1.8 mi | ★★★★★ | 14 | 0 |
| Villa Healthcare & Rehabilitation Center | 2.1 mi | ★★★★★ | 9 | 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.