Below average — CMS composite of the measures below.
The next survey window likely opens 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 Flagler Health And Rehabilitation Center during CMS and state inspections, most recent first.
RN Coverage Not Provided on Reviewed Days: The facility failed to ensure an RN, other than the DON, was on duty for at least 8 consecutive hours per day when census exceeded 60. Staffing sheets for two reviewed days showed only LPNs across all shifts, and the scheduler later verified that no RN had been assigned on those days.
Unlabeled and undated refrigerated foods were found in the walk-in and reach-in refrigerators, including gravy, cheese, cold cuts, and an unidentifiable orange food. In the dry storage room, a #10 can of spaghetti sauce was used to prop open the door, the juice box shelf was soiled, and the area under the 3-comp sink showed peeling paint, black buildup resembling mold or mildew, and debris. The deep fryer also had caked-on oil and food debris.
Before-breakfast insulin was given too early for several residents. Nurses completed the morning med pass before breakfast trays arrived, and sliding-scale rapid-acting or short-acting insulin was administered about 1.5 to 2 hours before meals instead of close to breakfast. The DON said staff were directed to give before-meal meds at 6:30 a.m., while the MDs stated insulin should be given within about 30 to 60 minutes of the meal.
Failure to Provide Fingernail Care: Two dependent residents did not receive consistent nail care. One resident with CVA and impaired grooming ability had elongated, jagged fingernails and said staff no longer trimmed them, while staff were unsure of the process and had no separate policy for diabetic nail care. Another resident with cognitive impairment and substantial hygiene needs was repeatedly observed with elongated nails and dark buildup under the nails, and the record showed no documented nail-care attempts during the review period.
A facility failed to timely assess and implement ordered care for surgical wounds for two residents. One resident with multiple traumatic surgical sites reported dressings had not been changed since admission, and records showed delayed wound monitoring and delayed wound documentation, with staff noting surgical wound care had not been addressed promptly. Another resident with a BKA and a right leg skin tear had both dressings left undated and unassessed until days after admission, while the TAR showed shift monitoring as completed despite no evidence of actual wound assessment. Staff interviews confirmed gaps in admission wound assessment, order follow-through, and documentation.
Two residents receiving continuous O2 therapy were observed with concentrators set at flow rates that did not match the physician orders. One resident with emphysema and chronic respiratory failure was repeatedly found on 4 LPM despite an order for a lower flow rate, and the concentrator filter had heavy dust buildup. Another resident with COPD was found on 3 LPM even though the current order was for 4 LPM, and an LPN adjusted the dial after confirming the order.
A resident received Midodrine despite documented blood pressures being at or above the ordered hold parameter, and the MAR showed doses signed off as given even though staff later stated at least one dose was not administered. In a separate case, a resident with severe cognitive impairment and persistent yelling, aggression, and anxiety was receiving multiple psychotropic medications, but the record lacked active behavior monitoring, documentation of non-pharmacological interventions, and side-effect monitoring despite staff describing ongoing symptoms.
The facility failed to keep the area around the commercial dumpsters clean and free of debris, and waste was not fully contained inside the receptacles. During kitchen tours, the dumpster area was observed with scattered trash including used gloves, paper, plastic bottles, baggies, cup lids, food containers, and other debris, and the DDS acknowledged the condition while stating he was unsure who was responsible for cleaning or maintaining the area.
Failure to Follow EBP PPE Requirements During Wound Care: A resident with a left shoulder wound, MRSA history, and contact isolation had wound care and repositioning performed without the required gown and glove PPE. The Wound Care Nurse and two CNAs were observed providing high-contact care without PPE despite an EBP stop sign outside the room and a PPE supply bin available; staff later stated they should have worn gowns and one CNA was not aware the resident was on EBP.
RN Coverage Not Provided on Reviewed Days
Penalty
Summary
The facility failed to ensure that an RN, other than the Director of Nursing, provided services for at least eight consecutive hours a day, seven days a week when the resident census exceeded 60 on two reviewed days. On 11/09/25, the staffing assignment sheets listed 12 nursing staff for all three shifts, but only LPNs were identified and no RN was scheduled; the unit assignment sheets for that day also listed only the staff shown on the assignment sheet, all of whom were LPNs. On 11/23/25, the staffing assignment sheets listed 11 nursing staff for all three shifts, again showing only LPNs and no RN; the unit assignment sheets for that day likewise identified only LPNs. On 12/4/25 at 2:30 PM, the scheduler reviewed the nursing hours for both dates on her computer and verified that no RN was assigned to work on those days, stating she was not aware the facility had not met its hours on those days.
Unlabeled refrigerated foods and unsanitary kitchen conditions
Penalty
Summary
Food was not stored and handled in accordance with professional standards in the kitchen. During an initial tour with the Director of Dietary Services, the walk-in refrigerator contained two steam table pans of a thick brown substance resembling gravy that were covered with plastic wrap but not labeled with the date the gravy was opened and placed into the pans. An opened block of orange pre-sliced cheese was loosely wrapped and exposed to air with no label or date, and two opened packages of cold cut meats were also wrapped and unlabeled. In reach-in refrigerator #1, a plastic bowl containing an unidentifiable orange-colored food was covered with a lid but was not labeled with the contents or dated. Additional kitchen storage and sanitation issues were observed. A #10 tin can of spaghetti sauce had been placed on the floor in the dry storage room to prop the door open. The shelf holding juice boxes was soiled with food particles and unidentified debris. Under the 3-compartment sink, the wall showed peeling paint and a black biological substance resembling mold or mildew, and the plastic sink pipes and tile baseboard were coated with similar black matter with debris accumulated underneath. The deep fryer had caked-on thick buildup of oil on the housing, sides, and tile floor underneath, and the fryer oil contained a foamy strip of food crumbs that had migrated to the front of the reservoir.
Before-Breakfast Insulin Given Too Early
Penalty
Summary
The facility failed to ensure accurate administration of time-sensitive insulin ordered to be given before breakfast for five residents reviewed. During observation on December 3 and December 4, RN C, LPN D, LPN V, and LPN E confirmed that morning medication passes had already been completed before breakfast trays arrived, and staff stated that before-meal medications were being given during the 6:30 a.m. medication pass. Breakfast trays were observed arriving later, beginning around 7:30 a.m. and ending as late as 8:15 a.m., meaning the insulin was administered well before the meal it was intended to cover. Resident #46 received sliding-scale Novolog before meals at 6:15 a.m. and 6:06 a.m. for elevated blood glucose readings, Resident #120 received sliding-scale Lispro at 6:05 a.m., Resident #10 received sliding-scale Regular insulin at 5:35 a.m., Resident #119 received sliding-scale Humalog at 5:34 a.m., and Resident #108 received sliding-scale Humalog at 5:33 a.m. In each case, the insulin was ordered before meals, but administration occurred approximately one and one-half to two hours before breakfast tray delivery. The MARs and administration timestamps confirmed these times. During interviews, the DON stated staff were directed by the company to administer before-meal medications at 6:30 a.m., describing this as close to a meal, but she was unsure of the facility policy. The Medical Director stated one hour before the meal was the clinical expectation, while another physician stated he expected insulin within 30 minutes prior to the meal and did not want fast-acting insulin given two hours before breakfast. The facility policy stated medications are to be administered in accordance with prescriber orders and that administration times are determined by resident needs, preference, and benefit, not staff convenience.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to provide ADL care, specifically fingernail care, for two dependent residents. Resident #54, who had a history of CVA and a BIMS score of 14/15 with upper extremity impairment requiring partial to moderate assistance with personal grooming, was observed on multiple occasions with elongated, jagged fingernails on both hands. He stated that staff used to take care of his fingernails but no longer did, and he said he could not trim them himself. RN staff later confirmed that he was diabetic and observed that his fingernails remained elongated and jagged. The DON stated that fingernail care could be provided by nurses and CNAs and that it was done upon request and on shower days, but there was no separate policy specific to fingernail care for diabetic residents. Resident #54’s care plan addressed skin impairment and potential ADL self-care deficit related to CVA, fatigue, hemiplegia, imbalance, and chronic medical conditions, but it did not include interventions for fingernail care or trimming. The resident’s record showed no behavioral concerns or refusals of care. Despite this, the fingernails remained untrimmed across repeated observations, and there was no documented schedule or clear process identified for ensuring fingernail care was completed for him. The facility also failed to provide adequate nail care for Resident #90, who had moderate cognitive impairment, required substantial assistance with personal hygiene, and was dependent on staff for personal hygiene needs. She was observed with elongated fingernails on her right hand with dark buildup under each nail tip on multiple days, and the condition persisted across observations. CNAs stated that facility-employed CNAs performed nail care, while agency CNAs did not assist with nail care for safety reasons; another CNA stated nurses clipped nails and CNAs cleaned and filed them. Resident #90 was not diagnosed with diabetes, yet there was no documentation of attempted nail care during the week leading up to the last observation, even though she had refused showers on two scheduled shower days and her bath schedule was twice weekly. Her care plan addressed ADL assistance, bathing, and resistiveness to care, but the record did not show nail care being addressed during the period reviewed.
Delayed Assessment and Documentation of Surgical Wounds
Penalty
Summary
The facility failed to ensure timely assessment and implementation of ordered care for surgical wounds for two residents. For one resident with multiple traumatic fractures and surgical sites involving the chest, neck, spine, left leg, arm, ankle, and abdomen, the record showed hospital discharge instructions for wound care and follow-up, but no surgical incision care orders were entered initially. Monitoring of the wounds did not begin until later, wound evaluation documentation did not begin until even later, and several skilled nursing notes did not mention wound care in the skin assessment or skilled services sections. The resident stated his dressings had not been changed since admission, and one chest dressing was observed without a date. The wound care nurse stated she had not always dated dressings and that she had begun doing surgical wound care only after realizing the wounds were not being addressed. The DON stated that if no surgical incision orders were present, staff should contact the physician or hospital, and the resident’s physician stated surgical wound care should begin within 24 hours of admission and that waiting two weeks to consult wound care was too long. For the second resident, who was admitted with a left below-the-knee amputation and diabetes, the admission assessment documented dressings on the left amputation site and the right lower extremity, but there was no assessment of either wound charted with the admission assessment. Orders dated later directed staff to monitor the left BKA site every shift for signs of infection, dehiscence, or other complications, yet the TAR showed those checks as completed each shift even though no evidence of wound assessment was found. The resident and his family stated the dressings had not been changed since admission, and both dressings were observed without dates. The wound care nurse confirmed that she was the first nurse to assess the wounds since admission and that she had not realized no one had assessed them before her evaluation. The facility’s own staff interviews showed that skin sweeps were expected on admission and weekly, but multiple nursing staff reported those sweeps were done on admission and with a change in condition. The DON stated the facility had no policy for surgical wound care, while the medical director stated staff should assess surgical wounds and contact the provider for orders. The facility policy required a comprehensive skin assessment on admission, documentation of changes in skin condition, notification of the physician and resident or representative of changes, and evaluation of surgical areas per physician orders.
Oxygen Therapy Not Delivered as Ordered
Penalty
Summary
The facility failed to ensure that two residents receiving continuous oxygen therapy were provided oxygen as ordered and in accordance with the facility’s oxygen administration guidelines. Resident #4 had diagnoses including emphysema and chronic respiratory failure with hypercapnia and had a physician’s order for oxygen via nasal cannula at 3 LPM, but was observed on multiple occasions with oxygen flowing at 4 LPM. During one observation, the resident was in bed eating lunch with the nasal cannula in place and the concentrator running at 4 LPM; during another, the resident was again in bed eating breakfast with oxygen flowing at 4 LPM. The resident stated he was supposed to receive oxygen at 4 LPM, while an LPN reviewed the record and verified the ordered flow rate was 2 LPM. The concentrator’s back filter was also observed to have a copious amount of light grey powdery buildup resembling dust. Resident #95 had a diagnosis of COPD and a physician’s order for oxygen via nasal cannula or mask, encouraging and assisting the resident to use oxygen at 4 LPM as needed for shortness of breath. When observed, the resident was lying in bed with the concentrator running at 3 LPM and stated the oxygen was supposed to be set at 3 LPM. An LPN later reviewed the electronic record and confirmed the order was for 4 LPM, then observed the concentrator set at 3 LPM and adjusted the dial to 4 LPM without explanation. The facility’s Oxygen Administration guidelines directed staff to review the physician’s order and adjust oxygen delivery so the appropriate flow was administered according to the resident’s needs.
Unnecessary medication administration and inadequate psychotropic monitoring
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when Midodrine was documented as administered multiple times despite the resident’s recorded systolic blood pressures being at or above the physician’s ordered parameter of less than 100. The resident had diagnoses including hypotension and a physician’s order for Midodrine 10 mg every eight hours as needed only for systolic blood pressure below 100. Review of the December 2025 MAR showed several doses signed off as given with blood pressure readings of 122/68, 119/64, 103/67, 111/63, 116/65, and 100/68. During interview, an LPN stated she did not give the medication at the time one dose was documented, while the MAR showed it as administered. The medication card was missing six tablets, and the MAR reflected eight doses signed off as administered between December 1 and December 4, 2025, even though no documented dose was given on the resident’s readmission date. The DON reviewed the MAR and acknowledged that a check mark indicated the medication was given and that nurses were trained to mark medications when administered. After reviewing the entries, she stated it looked like the medication was given as written and, when told the card showed six tablets missing, said the medication must have been given unless a pill fell out of the card. The physician stated he did not recall the issue and indicated that if Midodrine was being given daily he would schedule it routinely. The facility policy required medications to be administered safely and as prescribed, including verification of vital signs when necessary before administration. The facility also failed to ensure sufficient monitoring for a resident receiving psychotropic medication for mood and behavior. The resident had diagnoses including metabolic encephalopathy, cognitive communication deficit, anxiety disorder, major depressive disorder, unspecified dementia without behavioral disturbance, and mood disturbance, with a BIMS score of 3 indicating severe cognitive impairment. Staff described the resident as combative, aggressive, yelling out repeatedly, and difficult to redirect, and noted that medications such as scheduled Ativan, PRN Ativan, ABH gel, Depakote, and Mirtazapine did not control the behavior. Observations by surveyors found the resident repeatedly yelling out, demanding attention, and requiring frequent staff attention. Although the resident was care planned for impulsivity, aggression, hollering out, mood problems, and anxiety, the record contained no active monitoring of behaviors, non-pharmacological interventions offered, or side effects observed for the psychoactive medications. The DON initially stated behavior monitoring was expected, then reviewed a CNA task list that only showed when behaviors occurred and acknowledged there was no active behavior monitoring as required.
Dumpster Area Not Kept Clean
Penalty
Summary
The facility failed to ensure the area surrounding the commercial trash dumpsters was clean and free of debris and that all waste was contained inside the receptacle. During the initial kitchen tour with the Director of Dietary Services, the dumpsters behind the building were observed with scattered debris in the grassy and wooded area around and behind them, including used and inverted blue medical gloves, paper, plastic bottles, baggies and cup lids, a foam to-go food container, a cup, and other food containers. The DDS acknowledged the scattered trash but stated she was not sure who was responsible for cleaning it up or maintaining the dumpster area. On a later visit, the dumpster area was observed in the same condition, with trash still strewn about, and the visiting DDS stated he had not been advised of the condition and would have maintenance clean it up.
Failure to Follow EBP PPE Requirements During Wound Care
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precaution (EBP) requirements for PPE use during high-contact resident care activities for one resident with a left shoulder wound. On 12/03/25 at 12:54 PM, the Wound Care Nurse was observed providing wound care to the resident’s left shoulder wound with assistance from CNA J for turning the resident. A blue dressing on the wound was dated 12/01/25, and the nurse stated she had changed the dressing on 12/02/25 but had written the wrong date on it. Neither the nurse nor the CNA wore the PPE directed by the EBP notice posted outside the room, even though a PPE supply bin was available at the room entrance. Immediately after the wound care, the Wound Care Nurse stated she should have worn a gown and had simply forgotten. At 1:19 PM, CNA L and CNA J were observed repositioning the resident and pulling him up in bed after the wound care, and neither CNA wore PPE. Both CNAs stated they should have worn a gown because they were touching the resident, and CNA L stated she was not aware the resident was on EBP until then. The resident’s record showed he was admitted with a primary diagnosis of sepsis, had a history of MRSA of the left shoulder wound, required contact isolation, and was receiving antibiotics for MRSA/Strep Group A. The EBP stop sign outside the room directed staff to wear gowns and gloves for high-contact activities including dressing and wound care, and the facility policy stated EBP required gown and glove use for wound care and other high-contact resident care activities.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bunnell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Grand Oaks | 7.3 mi | ★★★★★ | 1 | 1 |
| Avante At Ormond Beach, Inc | 14.2 mi | ★★★★★ | 0 | 0 |
| The Pavilion At Crescent Lake | 15.5 mi | ★★★★★ | 13 | 0 |
| Coquina Center | 16.1 mi | ★★★★★ | 6 | 0 |
| Ormond Rehabilitation And Nursing Center | 16.3 mi | ★★★★★ | 29 | 0 |
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