Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capri Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairments reported that a male resident entered her room and attempted to get into bed with her, causing fear and sleep disturbances. The DON did not investigate the allegation, notify the resident's family, or inform the Administrator. The incident was assumed to be a misunderstanding involving a wandering resident, and a STOP banner was placed across the resident's doorway as a precaution.
A resident with communication difficulties reported that a male resident entered her room and attempted to get into bed with her, causing her to feel scared and unable to sleep. The facility failed to follow its policies for investigating such allegations, as the DON did not interview the resident, notify her family, or inform the Administrator. The incident was not thoroughly investigated, and the facility's response was inadequate.
The facility failed to maintain a safe and sanitary environment, with surveyors observing black substances on ceiling vents, cracked floors, peeling wallpaper, and black biogrowth in various areas. The Administrator acknowledged the building's aging condition and mentioned that repair plans were delayed due to staff being sent to sister facilities for hurricane preparation.
A facility failed to apply a physician-ordered orthotic device for a resident with contractures, leading to a deficiency. The resident, with Parkinson's disease and muscle weakness, was observed multiple times without the prescribed palm guards. Staff interviews revealed a lack of awareness and adherence to the orders, with the resident expressing confusion about the absence of the splints.
A resident with severe hearing impairment and a non-functional cochlear implant did not have a care plan addressing their need for closed captioning on the television. Despite the spouse's repeated requests, staff failed to turn on closed captioning, and the remote was out of reach. An LPN and the MDS coordinator confirmed the care plan lacked specific interventions for the resident's hearing needs.
The facility failed to provide necessary ADL care for three residents who were unable to perform these tasks independently. A resident with a pressure ulcer and malnutrition did not receive regular showers, and there was no documentation of her refusal or staff encouragement. Another resident with muscle weakness and falls only received bed baths, with no record of scheduled showers. A third resident with hemiplegia and contractures refused showers due to staff behavior, and her refusals were not documented or communicated to her family.
Two residents in the facility did not receive their prescribed Oxycodone pain medication consistently, leading to severe pain episodes. The MAR showed multiple missed doses, and staff cited pharmacy delivery issues as the cause. The DON was unaware of the specific missed doses and acknowledged problems with medication availability. The facility lacked regular interdisciplinary meetings to address these issues, and the Medical Director was not informed of the missed doses.
The facility's Memory Care Unit was found to have unsanitary conditions and improper storage of personal care items in six rooms. Observations included bed pans and wash basins on bathroom floors, unsecured lotions and creams, and cracked tiles with grime. Staff interviews revealed a lack of awareness and adherence to storage policies, with the DON admitting to not touring the unit and the RNC unsure of the policy for storing personal items.
Two residents with significant medical needs reported inadequate incontinence care, with delays in assistance and inconsistent toileting schedules. Despite care plans requiring two-person assistance, residents were often left wet for extended periods. Staff interviews revealed a lack of a structured toileting program, confirmed by the DON.
The facility failed to secure medications properly, with an unlocked medication cart left unattended and a resident self-administering antacid without assessment. An LPN admitted to leaving the cart unlocked due to an emergency, and the DON confirmed the lack of assessment for the resident's self-administration capability.
Failure to Investigate Allegation of Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures to investigate allegations of abuse and neglect for a resident diagnosed with Parkinson's disease, vascular dementia, anxiety disorder, muscle weakness, dysphagia, and cognitive communication deficit. The resident, who was last assessed as cognitively intact, reported that a male resident entered her room and attempted to get into bed with her, causing her fear and inability to sleep. Despite the resident's report, the Director of Nursing (DON) did not interview the resident, notify her family, or inform the Administrator of the allegation. The DON assumed that the incident was a misunderstanding involving a wandering resident and believed that placing a STOP banner across the resident's doorway was sufficient to ensure her safety. The report further indicates that the DON did not conduct interviews with other residents on the unit or take additional steps to investigate the incident. The Administrator acknowledged that such an incident might require reporting, depending on the situation. Additionally, a Licensed Practical Nurse (LPN) mentioned that while the night shift staff was aware of which residents could walk, there was no list of residents who wandered. The lack of a thorough investigation and communication with relevant parties highlights the facility's failure to adhere to its own policies regarding the handling of abuse and neglect allegations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Resident #1 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #1's care plan was reviewed and revised to include a stop sign on her doorway to deter any other residents from entering her room. On Social Service Director completed an assessment for resident #1. No concerns were noted related to the alleged deficient practice. On a grievance was filed on resident #1's behalf. On a thorough investigation was conducted regarding the allegation of a male resident entering resident #1's room. Results of the investigation did not rise to a level of meeting reporting criteria. On the Administrator and Director of Nursing were re-educated by the Regional Nurse Consultant on facility policy and procedures regarding reporting and investigation. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on current interviewable residents regarding neglect, and with focus on other residents entering their rooms. No additional residents were found to be affected by the alleged deficient practice. On the Director of Nursing/Designee completed a quality review of current resident progress notes for the past 7 days to identify any areas of concern that may require additional investigation. No further concerns noted. On the Director of Nursing/Designee completed a quality review of facility grievances for the past 30 days for any areas of concern that may require additional investigation. No further concerns noted. On a quality review was completed by Director of Nursing/Designee of current residents to identify any resident who may have potential to enter other residents' rooms. Care plans revised as appropriate. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By current facility staff were educated on the components of F607 with an emphasis on reporting and investigation by the Director of Nursing/Designee. By current Nursing staff were educated on characteristics and redirection techniques. Newly hired nursing staff will be educated on characteristics and redirection techniques by the Director of Nursing/Designee at orientation as a part of the systematic changes. Newly hired staff will be educated on the components of F607 with an emphasis on reporting and investigation by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 10 current residents' nursing progress notes 3 times a week for 4 weeks, then 1 time a week for 4 weeks, then 2 times weekly for 4 weeks, and then weekly for 4 weeks to ensure response/investigation for any potential allegations that meet federal reporting requirements. Administrator/Designee to conduct audits of Grievances 3 times a week for 4 weeks, then 2 times a week for 4 weeks, and then weekly for 4 weeks to ensure a response/investigation for any potential allegations that meet federal reporting requirements. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Investigate Allegation of Resident Mistreatment
Penalty
Summary
The facility failed to implement its policies and procedures for investigating allegations of neglect and mistreatment, as evidenced by an incident involving a resident who reported that a male resident entered her room and attempted to get into bed with her. The resident, who has a diagnosis of aphasia and communication difficulties, expressed feeling scared and unable to sleep following the incident. Despite the resident's report, the Director of Nursing (DON) did not interview the resident, notify her family, or conduct interviews with other residents on the unit. The DON also failed to inform the Administrator of the allegation, believing that the incident was likely a mistake and that a 'STOP' banner across the resident's doorway was sufficient to ensure her safety. The report highlights that the facility's policy on Neglect, Mistreatment, and Injury of Unknown Origin (ANEMMI) requires immediate reporting and investigation of such events, which was not adhered to in this case. The Administrator acknowledged that an incident of this nature could require reporting, depending on the situation. Additionally, the Hospice Director confirmed that the resident's daughter had reported the incident to the DON, yet no further action was taken. The lack of a thorough investigation and communication with relevant parties demonstrates a failure to follow established procedures for handling allegations of neglect and mistreatment.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 1 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #1's care plan was reviewed and revised to include a stop sign on her doorway to deter any other residents from entering her room. Social Service Director completed an assessment for resident #1. No concerns were noted related to the alleged deficient practice. A grievance was filed on resident #1's behalf. A thorough investigation was conducted regarding the allegation of a male resident entering resident #1's room. Results of the investigation did not rise to a level of meeting reporting criteria. The Administrator and Director of Nursing were re-educated by the Regional Nurse Consultant on facility policy and procedures regarding reporting and investigation. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A quality review was completed by Director of Nursing/designee on current interviewable residents regarding neglect, with a focus on other residents entering their rooms. No additional residents were found to be affected by the alleged deficient practice. The Director of Nursing/Designee completed a quality review of current resident progress notes for the past 7 days to identify any areas of concern that may require additional investigation. No further concerns noted. The Director of Nursing/Designee completed a quality review of facility grievances for the past 30 days for any areas of concern that may require additional investigation. No further concerns noted. A quality review was completed by Director of Nursing/Designee of current residents to identify any resident who may have the potential to enter other residents' rooms. Care plans were revised as appropriate. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current facility staff were educated on the components of N040 with an emphasis on reporting and investigation by the Director of Nursing/Designee. Current nursing staff were educated on characteristics and redirection techniques. Newly hired nursing staff will be educated on characteristics and redirection techniques by the Director of Nursing/Designee at orientation as a part of the systematic changes. Newly hired staff will be educated on the components of N040 with an emphasis on reporting and investigation by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee will conduct audits of 10 current residents' nursing progress notes 3 times a week for 4 weeks, then 1 time a week for 4 weeks, then 2 times weekly for 4 weeks, and then weekly for 4 weeks to ensure response/investigation for any potential allegations that meet federal reporting requirements. The Administrator/Designee will conduct audits of grievances 3 times a week for 4 weeks, then 2 times a week for 4 weeks, and then weekly for 4 weeks to ensure a response/investigation for any potential allegations that meet federal reporting requirements. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on both the first and second floors. During a tour, surveyors observed a black substance on the ceiling vents and surrounding ceiling tiles in several areas, including the Capri reading room, the first-floor hallway near the elevator, and the Social Service Office on the second floor. Additionally, the floor and cove base in various locations were found to be in poor repair, with cracks and separations. The wallpaper was peeling with orange discoloration in the memory care area near the speech therapy room and the second-floor hallway near the elevators. Black biogrowth was also noted on the walls and/or ceiling of the second-floor wall across from the elevator and the ceiling tiles of the second-floor storage room. In an interview, the Administrator acknowledged the aging condition of the building and mentioned that quotes for roof replacement had been sent to corporate for review. The Administrator confirmed that some work had begun on the walls and wallpaper, but progress was halted due to staff being sent to sister facilities in preparation for an impending hurricane. At the time of the interview, there was no definitive end date for the repairs, but efforts were being made to develop a plan.
Failure to Apply Physician-Ordered Orthotic Device
Penalty
Summary
The facility failed to consistently apply a physician-ordered orthotic device for a resident with contractures, leading to a deficiency in care. Resident #32, who has diagnoses including Parkinson's disease, anxiety, and muscle weakness, was observed multiple times without the prescribed bilateral palm guards. The physician's orders, dated June 28, 2024, required the use of these palm guards during the day shift, with removal only during hygiene care and meals. Despite these orders, the resident was seen without the splints on several occasions, and the splints were found on the nightstand instead of being worn by the resident. Interviews with staff revealed a lack of awareness and adherence to the physician's orders. CNA Staff A was unaware of the requirement for hand splints and had not seen the resident using them recently. During a joint observation, LPN Staff D confirmed the absence of the palm protectors, and the resident expressed confusion about their whereabouts, indicating that they were not applied by staff. The Occupational Therapist also confirmed that the resident was supposed to wear the palm guards daily, highlighting a breakdown in communication and execution of care plans within the facility.
Failure to Implement Resident-Centered Care Plan for Hearing-Impaired Resident
Penalty
Summary
The facility failed to develop a resident-centered care plan to meet the needs of a resident with impaired hearing. The resident, who was admitted with diagnoses including mixed conductive and sensorineural hearing loss and cochlear implant status, was found to have highly impaired hearing with an absence of useful hearing. Despite this, the care plan did not include specific interventions to address the resident's communication needs, particularly the need for closed captioning on the television, which was crucial for the resident's leisure activities. The resident's spouse repeatedly informed the staff about the importance of turning on closed captioning, as the resident was unable to do so independently. Observations revealed that the closed captioning was consistently not turned on when the resident was watching television, and the remote control was placed out of the resident's reach. Interviews with staff, including an LPN and the MDS coordinator, confirmed that there were no care plan interventions to remind staff to turn on the closed captioning. The MDS coordinator acknowledged the oversight in the care plan, which failed to individualize interventions to meet the resident's specific needs, despite the resident's significant hearing impairment.
Failure to Provide Necessary ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services for three residents who were unable to perform activities of daily living (ADLs) independently. Resident #999, who had a stage 4 pressure ulcer, protein-calorie malnutrition, and muscle weakness, was dependent on staff for bathing. Despite this, there was a lack of documentation regarding her refusal of showers and no evidence of staff attempts to encourage bathing. Observations revealed that Resident #999 appeared unkempt and reported receiving only a bed bath once a week. Resident #875, admitted with muscle weakness, repeated falls, and a compression fracture, required substantial assistance for bathing. However, she reported that staff only provided bed baths, citing convenience. Observations showed that her hair was greasy and uncombed, and her fingernails were dirty. The CNA task list lacked documentation of scheduled showers or any showers provided since her admission, and staff interviews revealed a lack of awareness regarding her care. Resident #900, with hemiplegia, hemiparesis, and contractures, was dependent on two staff members for bathing. She reported that staff were rude and did not introduce themselves, leading to her refusal of showers. Observations showed that she appeared unkempt, with matted hair and soiled bedding. Despite being alert and oriented, there was no documentation of staff efforts to encourage her to shower, and her son was not informed of her refusal of care. Interviews with staff indicated a lack of communication and documentation regarding her care refusals.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to provide pain medications in accordance with professional standards of practice and physician orders for two residents. Resident #99, who has diagnoses including colon cancer, rheumatoid arthritis, and major depressive disorder, reported not consistently receiving her scheduled Oxycodone 5 mg doses. The medication was supposed to be administered twice daily at 6:00 a.m. and 12:00 p.m., with additional doses available every six hours as needed. However, the Medication Administration Record (MAR) showed missed doses on several occasions, and the resident experienced severe pain rated at 10/10. The nursing staff documented that the medication was unavailable due to pharmacy issues, but there was no clear resolution or communication with the physician. Resident #399, with diagnoses including a right hip fracture, end-stage renal disease, and anxiety, also experienced issues with receiving her prescribed Oxycodone 5 mg three times a day. The MAR indicated missed doses on multiple dates, and there was no documentation explaining why the medication was not administered. The resident reported experiencing severe pain, but the facility staff failed to ensure the medication was available and administered as ordered. The Director of Nursing (DON) acknowledged the issues with the pharmacy and the delivery of medications but was unaware of the specific missed doses for Resident #99. The DON mentioned the use of the Pyxis system for emergency medication dispensing but did not have a clear process for addressing the recurring medication shortages. The facility lacked regular interdisciplinary team meetings to address ongoing issues, and the Medical Director was not informed about the missed doses for the residents.
Unsanitary Conditions and Improper Storage in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents in the Memory Care Unit, as observed during a survey. In six out of seventeen rooms, various deficiencies were noted, including unsanitary conditions and improper storage of personal care items. Specifically, bed pans and wash basins were found on bathroom floors, and personal care items such as lotions, creams, and sprays were improperly stored on nightstands and toilet tanks. Additionally, some bathrooms had cracked tiles and grime, and unsecured medical items like antifungal cream and nebulizer masks were left out in resident areas. Interviews with staff revealed a lack of awareness and adherence to proper storage policies. The Director of Nursing admitted to not having toured the unit, and a CNA was observed removing items from bathroom floors only after being instructed to do so. The Regional Nurse Consultant acknowledged the unsecured personal items and expressed uncertainty about the facility's policy for storing such items in the Memory Care Unit. The staff's inaction and lack of knowledge contributed to the unsanitary and potentially unsafe environment for residents, particularly those who wander and may be at risk of ingesting or misusing unsecured items.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services for residents who are incontinent of urine, as evidenced by the experiences of two residents. Resident #999, who has a stage 4 pressure ulcer, protein calorie malnutrition, and muscle weakness, reported being left in bed without assistance and not being changed promptly after incontinence episodes. The resident expressed concerns about being left wet, which is detrimental to their existing wound. The care plan for Resident #999 indicated a need for dependent assistance from two staff members for toileting, but the resident's account suggests this was not consistently provided. Similarly, Resident #900, with diagnoses including hemiplegia and contractures, reported that staff did not change them as frequently as claimed, often leaving them wet for extended periods. The care plan for Resident #900 also required two-person assistance for toileting, which was not consistently met according to the resident's account. Interviews with staff revealed inconsistencies in the understanding and implementation of toileting schedules, with some staff unaware of a formal toileting program. The Director of Nursing confirmed the absence of a structured toileting program, indicating a lack of clear guidelines for staff to follow in providing incontinence care.
Medication Security and Self-Administration Deficiencies
Penalty
Summary
The facility failed to secure all medications in a locked storage compartment, as observed on the East Wing medication cart, which was left unlocked and unattended. During an observation, two nurses were seen conversing in the hallway while the medication cart was not under their direct supervision. A resident in a wheelchair was observed passing by the unsecured cart. When questioned, an LPN admitted to leaving the cart unlocked due to an emergency, acknowledging the oversight. Additionally, a large bottle of antacid was found on a resident's bedside table, which the resident self-administered without proper assessment or authorization. The resident confirmed keeping the antacid at the bedside for self-use, and an LPN verified the presence of the medication but was unsure if self-administration was permitted. The clinical record showed a physician's order for the antacid but lacked an assessment to ensure the resident's capability to self-administer and securely store the medication. The DON confirmed the absence of such an assessment and was unaware of the resident's self-administration practice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 94 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Venice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advinia Care At Venice | 0.4 mi | ★★★★★ | 0 | 0 |
| Aviata At Venice | 1.5 mi | ★★★★★ | 6 | 0 |
| Sunset Lake Healthcare And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Venice Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Village On The Isle | 2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Capri Health And Rehabilitation Center.
100% money-back within 48 hours.
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.