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 Community Convalescent Center during CMS and state inspections, most recent first.
A resident with vertigo and multiple comorbidities, including Type 2 DM with neuropathy, heart failure, and CKD stage 3A, missed a scheduled ENT appointment when transportation arrived but the resident had not been informed of the appointment and was not prepared to go. The resident reported being told the appointment would be rescheduled, but this did not occur. An RN confirmed the appointment had to be rescheduled and that Medical Records staff handle such scheduling, while the CNA/Medical Records staff stated she was not aware the appointment needed rescheduling and later did not complete the task due to lack of time. The DON stated that appointments are expected to be followed up on timely, and the facility’s Transportation Services policy requires coordination with the Medical Records designee and timely rescheduling, which did not occur in this instance.
The facility did not ensure adequate kitchen staffing on several days, resulting in only one cook and one dietary aide present for meal shifts and requiring CNAs to be pulled from their regular assignments to assist in the kitchen. This led to delays in meal service, use of disposable serving ware, and missed resident care tasks such as showers, as CNAs' floor assignments were not always covered.
Surveyors identified extensive deficiencies in food storage, labeling, and sanitation, with numerous undated and unlabeled food items, spoiled produce, and improper storage of raw meats. Dietary staff failed to follow hand hygiene and glove use protocols, moving between tasks without washing hands or changing gloves. Cleaning and temperature logs were incomplete or missing, and the kitchen environment was unsanitary, with evidence of bio growth and insect activity. These findings reflect a failure to maintain a clean, safe, and sanitary environment in accordance with professional standards.
The facility did not update its facility-wide assessment to include emergency plans, required staff competencies for residents with different acuity levels, or specific staffing needs for each shift. Staff interviews revealed a lack of awareness and understanding of the assessment process, and the assessment itself was missing critical sections as identified during record review.
Surveyors identified multiple infection control deficiencies, including unattended open meal carts, failure to provide hand hygiene to residents before meals, unclean laundry areas with soiled linens and dust-covered equipment, an overfilled sharps container with syringes protruding above the fill line, and a dialysis patient with a red-stained towel and dirty fingernails. Staff interviews confirmed inconsistent cleaning and infection control practices.
The facility did not complete required antibiotic use monitoring for four months, with missing or incomplete surveillance forms and infection mapping. The DON, acting as Infection Preventionist, was unable to locate necessary documentation and had not educated nursing staff on proper form completion or infection control. Required audits and Quality Assurance reviews of antibiotic use were not documented as per policy.
Surveyors found multiple rooms with holes in walls, peeling ceilings, unpainted surfaces, missing baseboards, and bio growth in two wings. The Maintenance Director acknowledged responsibility but had not completed a comprehensive review, and only one room was listed in the work order system despite numerous deficiencies observed. Facility policies and job descriptions required proper maintenance, but these standards were not met in the affected areas.
The facility did not provide scheduled activities for residents on several observed days due to the absence of the Activity Director and lack of coverage, despite having an activity calendar and a policy requiring activities to meet residents' needs. Interviews with the DON and NHA confirmed that no one was available to conduct activities as planned.
Several residents were not offered the Influenza or Pneumococcal vaccines as required, and for those who were, there was no documentation of vaccine administration. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, and facility policy steps for consent, orders, and documentation were not consistently followed.
The facility did not ensure that three residents were properly offered and documented for the COVID-19 vaccine, with one not being offered the vaccine and two lacking documentation of administration after being offered. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, contrary to facility policy.
A resident with chronic health conditions reported missing and damaged clothing, and multiple residents expressed concerns about slow grievance resolution, especially regarding laundry. The facility did not provide evidence that grievances were resolved or that required follow-up actions were completed, and documentation was incomplete, contrary to facility policy.
The facility failed to complete a required Level II PASRR for a resident with multiple mental health diagnoses and did not ensure the accuracy of a Level I PASRR for another resident by omitting updated diagnoses. These deficiencies occurred despite facility policy requiring comprehensive preadmission screening and regular review of PASRR documentation.
Two residents were found with long, discolored fingernails and reported that staff had not offered or provided regular nail care, despite care plans instructing nail checks and trimming on bath days. Documentation showed inconsistent provision of nail care, incomplete shower logs, and lack of proper documentation for refusals. Staff interviews confirmed that nail care was not always performed, especially when CNAs were assigned to other duties, and the facility did not have a specific ADL policy.
A dependent resident with multiple medical conditions was not assisted out of bed by staff, despite her care plan requiring staff assistance for transfers. The resident reported not receiving help to use the toilet or attend activities, and was observed lying in bed on several occasions. Staff interviews confirmed that assistance was only provided upon resident request, which was inconsistent with facility policy and the resident's care plan.
A resident with multiple chronic conditions and intact cognition was observed to have severely overgrown and malformed toenails. Although the resident expressed a need for podiatry care, staff had not ensured timely assessment or referral to podiatry services. Documentation did not specify whether toenail care was provided, and facility leadership was unclear about the referral process and podiatry visit frequency.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment.
Two residents with complex medical needs experienced significant, unaddressed weight loss due to inadequate monitoring, lack of updated care plan interventions, and insufficient interdisciplinary communication. Both residents reported dissatisfaction with their diets and did not receive appropriate dietary modifications or supplements in a timely manner, despite clear evidence of nutritional decline.
A resident with a PICC line had a soiled dressing that was not changed according to physician orders and facility policy, despite visible signs of soiling and documentation discrepancies. The DON confirmed the dressing was not changed as required, and the facility's infection prevention policy was not followed.
The facility did not consistently post the Daily Nursing Staffing form as required, with outdated information displayed at the entrance and no posting on the 2nd floor. Staff interviews confirmed the form was not updated daily and was only posted at the front, and there was no facility policy addressing this requirement.
A medication error rate of 6.67% was identified when an LPN administered medications to a resident after updating orders for a probiotic and stool softener, but before the new orders were scheduled to begin. The LPN did not follow facility policy to confirm the timing of medication orders on the MAR prior to administration, resulting in two errors during thirty observed opportunities.
A resident with a history of stroke, dementia, and dysphagia, who required staff assistance and supervision during meals, was left unsupervised with a meal tray and consumed food without help. Staff failed to check the care plan or provide the necessary support, and the resident received an incorrect food item. The resident was later found unresponsive, required emergency interventions, and died after being transported to the hospital. The deficiency was due to staff not following the care plan and not ensuring proper supervision and dietary management.
A resident with dementia, dysphagia, and a history of stroke, who required staff assistance and supervision during meals, was left unsupervised with a meal tray. Staff failed to follow the care plan and did not check the resident's needs before providing the meal. The resident was later found unresponsive after eating alone, required emergency interventions, and subsequently died. The deficiency was due to staff not implementing required care plan interventions for safe feeding.
A resident with dementia, dysphagia, and a history of stroke was left unsupervised and without assistance during a meal, despite care plan and speech therapy recommendations requiring staff support. The resident consumed her meal alone, was later found unresponsive, and emergency interventions were initiated for suspected choking. Documentation and interviews confirmed that staff did not follow the care plan or provide the necessary supervision, leading to the resident's death.
Failure to Coordinate and Reschedule ENT Appointment for Resident with Vertigo
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and follow through with an outside Ear, Nose and Throat (ENT) medical appointment for one resident. On 04/08/2026, the resident was observed in bed in a nightgown and reported having vertigo and being scheduled to see an ENT specialist. He stated that on the day transportation arrived for the appointment, he was not ready because no one at the facility had informed him of the appointment, and that this occurred about a month prior. He further stated the facility told him the appointment would be rescheduled, but it never occurred. Record review showed the resident was originally admitted on 10/10/2023 and readmitted on 02/26/2026 with diagnoses including Type 2 DM with diabetic neuropathy, heart failure (unspecified), and CKD stage 3A. An order summary dated 04/08/2026 showed an ENT appointment scheduled for 02/11/2026 at 11:00. In an interview, an RN confirmed the resident had an ENT appointment on 02/11/2026 for vertigo that had to be rescheduled and stated that Medical Records staff are responsible for scheduling appointments, but she did not know if the appointment was ever rescheduled. The CNA/Medical Records staff member reported that the NP had informed her that the resident wanted to see the ENT, but she was not made aware that the appointment needed to be rescheduled after it was missed. She stated that on a Monday shortly before the survey, the NP asked if she had rescheduled the ENT appointment, and she told the NP she would get to it but did not reschedule it because she did not have time. The DON stated his expectation that appointments should be followed up on timely. The facility’s Transportation Services policy, dated 02/2025, states that the facility will arrange transportation services as needed to ensure each resident receives a complete continuum of service consistent with the plan of care and outlines procedures for notifying the Medical Records designee and rescheduling appointments when necessary, which were not followed in this case.
Insufficient Kitchen Staffing and Inappropriate Use of CNAs
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service on four out of eight days reviewed. Observations and punch detail reports showed that on multiple occasions, only one cook and one dietary aide were present for meal shifts, and certified nursing assistants (CNAs) were pulled from their regular assignments to assist in the kitchen. Staff interviews confirmed that it was common for the kitchen to be understaffed, resulting in delays in meal service, use of disposable serving ware due to lack of dishwashing support, and CNAs being reassigned without coverage for their original duties. The interim Food Services Manager was unsure about the adequacy of kitchen staffing, and the Staffing Coordinator acknowledged that CNAs had to fill in for kitchen staff, though she claimed it was not frequent. Further interviews revealed that when CNAs were moved to the kitchen, their floor assignments were not always covered, leading to missed resident care tasks such as showers. The Nursing Home Administrator stated that the Dietary Manager was responsible for kitchen staffing and that CNAs were not given additional training when assisting in the kitchen, as their duties were limited to tray service. Facility policy required ongoing monitoring and evaluation of staffing adequacy, but the documented practices and staff statements indicated that these procedures were not consistently followed, resulting in insufficient kitchen staffing and disruption of both dietary and resident care services.
Widespread Food Storage, Sanitation, and Hand Hygiene Failures in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and nourishment rooms regarding food storage, labeling, sanitation, and staff hygiene practices. Numerous food items in the walk-in refrigerator, freezer, and dry storage were found to be undated, unlabeled, and in some cases, visibly spoiled or contaminated with bio growth. Open containers of milk, fruit bowls, and various other food items lacked proper labeling and dating, while some produce and meats were observed with mold or other signs of spoilage. Additionally, food items were not always stored in accordance with professional standards, with raw meats improperly stored and prepared foods left uncovered or inadequately covered. Staff were repeatedly observed failing to follow proper hand hygiene and glove use protocols. Several dietary staff members were seen moving between tasks such as plating food, handling dirty dishes, and performing temperature checks without washing hands or changing gloves as required. Staff were also observed scratching their heads, picking items up from the floor, and then resuming food preparation duties without performing hand hygiene. These lapses occurred despite facility policies mandating hand washing before and after glove use, between tasks, and after contact with unsanitary surfaces. Sanitation and cleaning logs were incomplete or missing, with dishwashing and refrigeration temperature logs showing multiple unrecorded dates. The kitchen environment was found to be unsanitary, with dirty pots and pans left in sinks, food particles and bio growth present in various areas, and evidence of insect activity near dishwashing equipment. The facility's own policies require daily, weekly, and monthly cleaning schedules, as well as proper documentation of cleaning and temperature checks, but these were not consistently followed or documented. Staff interviews confirmed a lack of adherence to established procedures for food storage, labeling, and sanitation.
Facility Assessment Lacks Emergency and Staffing Details
Penalty
Summary
The facility failed to update its facility-wide assessment to include necessary components such as emergency plans, staff competencies required for caring for residents with varying acuity levels, and specific staffing needs for each shift. Review of the existing facility assessment revealed it lacked sections addressing these critical areas. During interviews, the Staffing Coordinator indicated she was unaware of the facility assessment and based daily staffing solely on the current census, without reference to a comprehensive assessment. The Nursing Home Administrator reported updating the assessment upon arrival to the facility, focusing on a general overview of the building, residents, services, and employee information, but did not include the required details regarding emergency preparedness, staff competencies, or shift-specific staffing needs. No policy related to the facility assessment was provided.
Infection Control Lapses in Meal Service, Laundry, and Sharps Management
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control program. Meal carts on two separate floors were left open and unattended, exposing unused food trays in foam containers to the environment. Staff were seen delivering meal trays to residents without offering hand hygiene prior to meals in one hallway and two dining rooms. Additionally, eating utensils were left open to the environment and unattended while staff passed meal trays. The facility's hand hygiene policy did not address providing residents with hand hygiene before meals. In the laundry room, several infection control lapses were noted. A personal cell phone was found on the table used for folding linens, and the wall air conditioning unit and a floor fan, both in use, were covered in dust. One dryer was not working and was being used to store clean clothes, while the vents under other dryers contained lint. The area around the washers was dirty, with water stains, a soiled blanket on the floor, and uncleanable porous foam tubes with crusty substances on one washer. Staff interviews confirmed that some of these issues had been ongoing and that cleaning practices were not consistently effective. A resident receiving dialysis was observed with a red-stained towel under the left upper arm, reportedly from a bleeding dialysis site, and had long, dirty fingernails. The resident stated that staff did not offer hand hygiene before meals. Additionally, a sharps container attached to a treatment cart was found to be overfilled, with syringes sticking out above the fill line, contrary to the container's labeling. These findings were supported by photographic evidence and were not in accordance with the facility's infection prevention and control policy.
Failure to Implement and Monitor Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement and monitor its antibiotic stewardship protocol as required. Record reviews and interviews revealed that antibiotic use monitoring was not completed for four consecutive months. Specifically, the Antibiotic Stewardship Book lacked surveillance documentation for August, and the forms for May, June, and July were incomplete and missing required information. The infection mapping for these months was also absent. The DON, who serves as the Infection Preventionist, was unable to locate necessary forms and had not provided education to nurses on how to properly complete the surveillance forms. Additionally, she acknowledged that she had not educated staff on infection control practices. The facility's policy requires comprehensive documentation for antibiotic prescriptions, including dose, route, duration, start and end dates, planned days of therapy, and indication. Audits of antibiotic prescriptions and monitoring of community-acquired infection prevalence data are also mandated, with findings to be presented at monthly Quality Assurance meetings. However, the DON could not provide evidence of such discussions or documentation for several months, nor could she locate point prevalence rates for the same period. The DON stated that she does not allow prophylactic antibiotic orders by physicians, but the lack of surveillance and documentation indicates the protocol was not followed as outlined in facility policy.
Failure to Maintain Safe and Homelike Environment Due to Building Disrepair
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in two of its four wings, specifically 100 East and 200 East. During facility tours, multiple rooms were found with holes in the walls, peeling ceilings, unpainted walls, missing baseboards, and bio growth on window sills. These deficiencies were directly observed on two separate dates, with photographic evidence obtained. The Maintenance Director acknowledged responsibility for building upkeep but admitted that a comprehensive room-to-room review had not been completed. The process for reporting and addressing maintenance issues involved staff entering work orders into an electronic system, which the Maintenance Director then prioritized. However, only one room with wall damage was listed as open or in progress in the work order documentation, despite the multiple deficiencies observed. During interviews, the Maintenance Director was unable to provide explanations for the unresolved issues in several rooms and stated there was no current resolution for fixing certain problems, such as ceiling damage or relocating residents from affected areas. Review of the facility's policies and the Maintenance Director's job description confirmed the expectation for maintaining the building in good repair and ensuring a safe environment for residents. Despite these requirements, the observed conditions indicated a failure to uphold these standards in the affected wings.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide scheduled activities for residents on three out of four days observed. Observations on multiple occasions throughout the days revealed that no activities were conducted as listed on the activity calendar, including events such as Pokeno, Blackjack, Church, Room Visits, Movement and Music, Sing a Long, Bingo, and Movie Monday. The activity calendar indicated that these activities were planned, but they did not occur as scheduled. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the absence of the Activity Director, who had been out since the previous Friday, and the subsequent call-out of the assigned replacement, resulted in no one being available to conduct activities. The NHA acknowledged that there should have been coverage for activities when the Activity Director was unavailable. Review of the facility's policy indicated that activities should be provided at a frequency to meet the individual needs of residents, including their medical, emotional, spiritual, therapeutic, and recreational needs.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were consistently offered and administered the Influenza and Pneumococcal vaccines as required. Record reviews for four out of five sampled residents revealed that several were not offered the Influenza vaccine, and for those who were, there was no documentation indicating receipt of the vaccine. Similarly, some residents were not offered the Pneumococcal vaccine, and for others, there was no documentation of administration despite being offered. The facility's policy requires annual offering and documentation of these vaccines, including obtaining consent and physician orders, but these steps were not consistently followed. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to residents regarding the vaccines, although the facility policy requires staff to complete a form when education is provided. The lack of adherence to policy and incomplete documentation contributed to the deficiency in ensuring residents were properly offered and administered the required vaccinations.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were properly offered and documented for the COVID-19 vaccine, as evidenced by record reviews and interviews. Specifically, three out of five sampled residents were not managed according to facility policy: one resident was not offered the COVID-19 vaccine at all, while two others were offered the vaccine but had no documentation indicating whether they received it. The facility's policy requires that all residents be offered the COVID-19 vaccine and any eligible boosters, with proper documentation of administration, consent, or declination in the medical record. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked any residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to any residents regarding the COVID-19 vaccine, despite the existence of a form for documenting such education. The facility's policy outlines specific procedures for offering, obtaining consent, and documenting immunizations, which were not followed in these cases.
Failure to Follow Grievance Process for Laundry-Related Complaints
Penalty
Summary
The facility failed to follow its grievance process for a resident who reported multiple issues with missing and damaged clothing, as well as concerns about laundry practices. The resident, who had diagnoses including type 2 diabetes and chronic kidney disease, reported missing three pairs of cargo pants and damage to other clothing items after laundering. Despite the resident filing grievances and being told the items would be replaced, the facility did not provide evidence that the items were replaced or that the grievances were resolved. Documentation in the grievance log and reports was incomplete, with missing resolution dates and lack of confirmation that the issues were addressed. The Nursing Home Administrator was unable to specify what actions had been taken regarding the grievances and acknowledged that grievances were marked as completed without the required follow-up or proof of resolution. Additionally, during a resident council meeting, multiple residents expressed concerns about the facility's slow response to grievances, particularly regarding laundry issues. Residents reported missing and damaged clothing and a lack of communication about the outcomes of their grievances. The facility's grievance policy requires prompt efforts to resolve concerns and documentation of resident satisfaction upon completion, but these procedures were not followed as evidenced by incomplete records and unresolved issues.
Deficient PASRR Screening and Documentation for Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to complete a required Level II Pre-admission Screening and Resident Review (PASRR) for one resident and did not ensure the accuracy of a Level I PASRR for another. One resident was admitted with diagnoses including unspecified bipolar disorder, insomnia, and depression, and their PASRR indicated diagnoses of bipolar disorder, depressive disorder, and PTSD. Despite these diagnoses and the resident exhibiting symptoms of depression following the loss of a spouse, the PASRR did not identify any disorder resulting in functional limitations or issues with interpersonal functioning, and it was determined that a Level II PASRR was not required. The resident's care plan, however, included trauma-informed care for PTSD and the use of psychotropic medications for bipolar disorder and insomnia. The Director of Clinical Reimbursement confirmed that a Level II PASRR should have been completed for residents with such diagnoses who remain in the facility for more than 30 days. For another resident, the facility did not update the Level I PASRR to reflect new diagnoses of anxiety and insomnia that were added after the initial admission. The PASRR only listed depressive disorder, omitting the later diagnoses. The Director of Clinical Reimbursement stated that updating PASRRs is typically the responsibility of Social Services, but there was uncertainty about the regular review process for PASRRs and whether all relevant diagnoses were being consistently documented. The facility's policy requires preadmission screening and review of PASRRs for suspicion of serious mental illness or intellectual disability, but these procedures were not followed as required in these cases.
Failure to Provide Adequate Nail Care for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate nail care for two residents who were sampled for activities of daily living (ADLs). One resident was observed multiple times with fingernails extending 1/3 to 1/2 inch past the fingertips, discolored, and with a dark substance present. The resident reported not wanting long fingernails and stated that staff had not offered to cut them, with documentation showing nail care was only provided eight out of twenty-seven days. The resident's care plan indicated a self-care performance deficit related to weakness and activity intolerance, as well as impaired cognitive function due to dementia, but did not address any behaviors related to refusing care. Staff interviews confirmed that nail care should be provided by CNAs or nurses, with special consideration for diabetic residents. Another resident was observed with long fingernails and a dark brown substance caked underneath. This resident expressed a preference for regular nail care and reported that staff did not mention or offer to cut fingernails, and that toenail care was only provided once every two months. The resident indicated willingness to perform self-care if supplies were available. Documentation revealed several days where nail care was not provided, and shower logs were incomplete for the requested period. Staff interviews indicated that refusals for ADL care were not consistently documented with reasons, and that ADL care may not be provided when CNAs are assigned to other duties. The facility's care plan for one resident instructed staff to check and trim nails on bath days and as necessary, but records showed this was not consistently done. The facility lacked a specific ADL policy, and the process for documenting refusals was not always followed according to the facility's own declination form. Photographic evidence was obtained to support the findings.
Failure to Assist Dependent Resident with Transfers and Activities of Daily Living
Penalty
Summary
A deficiency occurred when a dependent resident was not provided assistance to get out of bed, despite being unable to perform this activity independently. Observations on multiple occasions showed the resident lying in bed with her call light within reach, reporting that staff would not assist her to the toilet or help her attend activities. The resident, who had diagnoses including muscle wasting, atrophy, a femur fracture, and diabetes, was cognitively intact according to her BIMS score. Her care plan specified that she required assistance from one staff member for transfers, with the goal of preventing decline in her ability to perform activities of daily living (ADLs). Interviews revealed that a CNA assigned to the resident had not assisted her out of bed and only did so when residents specifically requested it. The DON confirmed that all residents should be offered the opportunity to get out of bed, regardless of whether they ask. The CNA job description also outlined responsibilities for assisting residents with transfers and mobility. The failure to provide necessary assistance resulted in the resident remaining in bed and missing activities, contrary to her care plan and facility policy.
Failure to Provide Timely Podiatry Services for Resident with Foot Care Needs
Penalty
Summary
The facility failed to assess and obtain podiatry services for a resident with significant foot care needs. Observations revealed that the resident's toenails were malformed, thickened, discolored, and extended past the tips of the toes. The resident expressed a need for a podiatrist to cut their toenails. Staff interviews indicated that the resident's name was placed in a folder for the Social Worker to add to the podiatry list, but the issue had not been previously brought to the attention of nursing staff by aides. Documentation showed that nail care was provided as needed, but did not specify whether this included toenails, and there was no evidence that the resident had refused podiatry or nail care services. The resident had multiple medical diagnoses, including chronic respiratory failure, end stage renal disease, and dependence on dialysis, and was cognitively intact. Physician orders allowed for podiatry services as needed, and the care plan required assistance with personal hygiene. Interviews with facility leadership revealed uncertainty about the frequency of podiatry visits and a lack of clarity regarding the process for referring residents to podiatry services. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a breakdown in communication and follow-through regarding the resident's foot care needs.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Nutritional Status and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, specifically body weight, for two residents who experienced significant weight loss. One resident, with multiple diagnoses including muscle wasting, anemia, dysphagia, diabetes, and depression, lost 15.15% of body weight since admission. Despite triggering for significant weight loss, the care plan and interventions were not updated after the loss was identified. The resident reported not eating the provided food due to dislike and not being offered alternatives or snacks, and staff interviews confirmed a lack of new dietary interventions following the weight loss. Another resident, also with complex medical conditions such as muscle wasting, dysphagia, and GERD, lost 8.31% of body weight in just over a month. The resident was on a pureed diet and reported not liking the food, having difficulty eating due to dental issues, and not receiving adequate dietary variety. The nutrition evaluation noted the resident was not meeting estimated nutritional needs, and although a supplement was recommended, the care plan did not reflect updated interventions after the significant weight loss was discovered. The order for weekly weights, as recommended by the dietitian, was not present in the physician orders. Interviews with staff, including the DON and SLP, revealed a lack of awareness and communication regarding the residents' weight loss. The SLP was not informed of the weight loss, and the DON was unaware of the extent of the issue or the absence of weekly weight orders. The facility's policy required more frequent monitoring and interdisciplinary communication for significant weight loss, but these steps were not documented or implemented for the affected residents.
Failure to Change Soiled PICC Line Dressing per Policy
Penalty
Summary
The facility failed to ensure the intravenous catheter dressing for a resident with a peripherally inserted central catheter (PICC) was changed according to professional standards and facility policy. Observations revealed that the resident's PICC line dressing was soiled, with a dark dry-looking substance and a red wet-looking substance visible under the clear dressing. The dressing was dated several days prior and had not been changed as required. Review of the resident's physician orders indicated that the IV dressing was to be changed every 7 days and as needed (PRN) for soiling or dislodgement. However, the Medication Administration Record (MAR) showed that while the dressing was documented as changed on certain dates, it was not actually changed when soiled, as required by the orders. Interviews with the Director of Nursing (DON) confirmed that the dressing had not been changed as documented and that the dressing should have been changed when soiled. The facility's infection prevention policy required transparent, semi-permeable membrane dressings to be changed at least every 7 days and PRN if the dressing became wet, loose, soiled, or if skin integrity was compromised. The failure to change the dressing as needed for soiling was confirmed through observation, record review, and staff interviews.
Failure to Appropriately Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to appropriately post the Daily Nursing Staffing form as required. Observations revealed that the posted form near the reception area was outdated, displaying a date from three days prior. Additionally, the Daily Nursing Staffing form was not posted on the 2nd floor during multiple observations over several days. Interviews with the Staffing Coordinator and the Nursing Home Administrator confirmed that the form was only posted at the entrance and not updated daily as required. It was also noted that the facility did not have a policy related to the posting of the nursing staffing form.
Medication Error Rate Exceeds 5% Due to Improper Timing of Order Changes
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two medication errors identified during the observation of thirty medication administration opportunities. Specifically, an LPN administered nine medications to a resident, including changes to the resident's probiotic and stool softener, after receiving new orders from the provider. The LPN updated the electronic medication profile and administered the medications, but the new orders for docusate (from capsule to tablet) and for the probiotic (from lactobacillus to saccharomyces) were scheduled to begin at later times, not at the time of administration. The LPN documented the administration in the electronic record, but the timing did not align with the scheduled start of the new orders. Review of the resident's Medication Administration Record (MAR) confirmed that the previous orders for docusate and lactobacillus were discontinued just prior to the administration, and the new orders were set to begin later in the day. The DON confirmed that both medications should have been administered after the new orders became active. Facility policy requires staff to review and confirm medication orders on the MAR prior to administration, but this procedure was not followed, resulting in a medication error rate of 6.67%.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglect by not ensuring supervision and assistance during mealtimes, despite the resident's documented need for such support due to a history of cerebral infarction, dementia, and dysphagia. The resident was dependent on staff for feeding, as indicated in her care plan and medical records, which specified a mechanically altered diet and substantial/maximal assistance with eating. On the day of the incident, staff provided the resident with a covered food tray in her room and left her unsupervised, allowing her to consume her meal without the required assistance or monitoring. The resident was later found unresponsive by her roommate, who alerted a nurse. Facility staff initiated emergency interventions, including the Heimlich maneuver and CPR, and Emergency Medical Services were called. The resident was transported to the hospital, where she expired. Interviews and documentation revealed that staff did not check the resident's care plan prior to providing the meal, and there was a lack of communication and understanding among staff regarding the resident's need for supervision and assistance during meals. Additionally, the resident received the wrong food item on her tray, which was not consistent with her prescribed diet. Further investigation showed that the resident's family and speech language pathologist had previously communicated the need for supervision during meals due to the resident's tendency to eat too quickly and her inability to sense food on one side of her mouth. Despite these recommendations, staff routinely left the resident to feed herself and did not provide the necessary supervision or assistance. The facility's failure to follow the care plan and ensure proper supervision and dietary management directly contributed to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals.
- Facility staff were provided education by the DON or designee regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. Contracted staff members were provided education regarding abuse, neglect, and misappropriation. Nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held.
Failure to Implement Care Plan Interventions for Assisted Dining
Penalty
Summary
A deficiency occurred when facility staff failed to implement care plan interventions for a resident with a history of cerebral infarction, dementia, and dysphagia, who was dependent on staff for feeding and required supervision during meals. Despite clear documentation in the care plan and recommendations from the speech language pathologist for close supervision and assistance with eating, the resident was left unsupervised with a meal tray in her room. Staff did not check the care plan prior to providing the meal, and the resident consumed food without the required assistance or supervision. The resident, who had moderate cognitive impairment and was on a mechanically altered diet, was found unresponsive after eating unsupervised. Interviews and medical record reviews confirmed that the resident had a history of difficulty swallowing, required a mechanically soft diet, and was dependent on staff for eating. The care plan specifically indicated the need for one staff member to assist with eating and for supervision due to the resident's cognitive deficits and swallowing risks. However, staff members, including CNAs and LPNs, did not follow these interventions, and some were unaware of the resident's needs, relying instead on verbal shift reports or assumptions about the resident's abilities. As a result of these failures, the resident was discovered unresponsive with food present, required emergency interventions including the Heimlich maneuver and CPR, and was subsequently transported to the hospital, where she expired. The investigation revealed that staff did not consistently review or implement care plan interventions, and the resident was not provided the necessary supervision and assistance during meals as required by her care plan and physician orders.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- An audit was completed of care plans for current residents related to necessary dietary interventions to ensure that residents requiring assistance receive appropriate care during mealtimes as per the resident care plan and CNA documentation system. The audits for meal tray accuracy and appropriate level of assistance were initiated and is currently ongoing. There are currently 50 audits at this time. The tray line audit reviewing adequate consistency and items matching meal tickets was initiated and is ongoing, there are currently 118 audits at this time.
- The DON and NHA received directed education by the Regional Nurse Consultant on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions.
- A total of 90 out of 90 Licensed nursing staff and Certified Nursing Assistants were provided education by the DON or designee on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, and dysphagia was not provided the required supervision and assistance during mealtime, as outlined in her care plan and supported by speech therapy recommendations. The resident was dependent on staff for feeding and required a mechanically altered diet, yet staff failed to check her care plan before delivering her meal tray and left her unsupervised in her room. The resident consumed her meal without assistance, despite documented needs for close supervision due to her cognitive impairment and swallowing difficulties. On the day of the incident, the resident was found unresponsive by a nurse after her roommate alerted staff. The nurse and other staff initiated emergency procedures, including CPR and the Heimlich maneuver, due to suspected choking. EMS arrived and continued resuscitation efforts, noting the presence of emesis and food in the resident's airway. The resident was transported to the hospital, where she later expired. Documentation and interviews confirmed that the resident had not been consistently assisted or supervised during meals, and her care plan interventions were not followed by the staff responsible for her care. Interviews with facility staff, the resident's family, and the speech language pathologist revealed that the resident's need for supervision and assistance during meals was known but not consistently communicated or implemented. Staff members involved in meal delivery and care did not review the care plan or receive adequate handoff information regarding the resident's needs. The failure to provide supervision and assistance during meals, as required by the resident's care plan and clinical recommendations, directly led to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding ensuring proper resident supervision and/or assistance during meals is occurring.
- A total of 104 out of 104 nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 188 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plant City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Plant City | 3.1 mi | ★★★★★ | 0 | 0 |
| Victoria Crossing Rehabilitation Center | 10.3 mi | ★★★★★ | 11 | 0 |
| Bridgewalk On Harden Health And Rehabilitation, Ll | 10.6 mi | ★★★★★ | 0 | 0 |
| Aviata At Central Park | 10.9 mi | ★★★★★ | 3 | 0 |
| Aviata At Oakfield | 11.3 mi | ★★★★★ | 23 | 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.