Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain Manor Health & Rehabilitation Center during CMS and state inspections, most recent first.
Oxygen therapy was not delivered at the ordered flow rates for three residents. One resident with acute respiratory failure and COPD had O2 observed at 1.5 to 2 LPM via NC when the order was for 2 LPM PRN for SOB; another resident with acute respiratory failure had O2 observed at 2 LPM via NC when the order was for 3 LPM via NC, titrate to 5 L to keep SpO2 above 93%; and a third resident with CAD had O2 observed at 2.5 LPM via NC when the order was for 2 LPM PRN for SOB. Staff stated they verify oxygen orders against concentrator settings during shifts.
A resident with dementia and other medical conditions was physically abused by a mental health technician, who roughly pulled the resident from a chair, resulting in a fall and subsequent injuries. The incident was witnessed by another resident and confirmed through interviews and review of facility records, revealing that the staff member's actions were rough and unnecessary, causing physical harm.
A resident with cognitive and mobility impairments was physically abused by a mental health technician, who roughly pulled the resident from a chair, resulting in a fall and subsequent injuries. The incident was not reported by the staff member, but was witnessed by another resident and later confirmed through interviews and video review. The facility's internal investigation verified the occurrence of physical abuse.
A medication/treatment cart was found unlocked and unattended in a hallway. A nurse later admitted to leaving the cart unlocked by mistake while assisting a resident, and the DON confirmed that protocol requires carts to be locked when unattended. Facility policy also mandates that medications be stored in locked compartments accessible only to authorized personnel.
A resident with severe cognitive impairment and a history of falls experienced a fall, but staff failed to notify the family or responsible party as required. Documentation showed that while the MD was notified, no next of kin was listed or contacted, and staff interviews confirmed the lack of family notification despite facility policy.
Facility staff did not notify a resident's family or representative after a fall, despite the resident being at high risk for falls and severely cognitively impaired. Documentation showed the physician was informed, but no responsible party was listed or contacted, and staff interviews confirmed the required notification process was not followed.
A medication/treatment cart was found unlocked and unattended in a hallway by a surveyor. The assigned wound care nurse admitted to leaving the cart unsecured while assisting a resident, in violation of facility policy and federal regulations requiring medications to be stored in locked compartments.
Two residents with indwelling urinary catheters did not receive proper catheter care according to professional standards. Staff failed to perform hand hygiene before procedures and used incorrect cleaning methods, such as using personal soap and not changing washcloths. The residents had diagnoses including UTIs and required specific care interventions, which were not followed. Staff training inconsistencies were noted, with some staff lacking proper in-service training on catheter care.
The facility failed to implement proper infection control measures during catheter care for two residents, increasing the risk of UTIs. Staff did not perform hand hygiene before procedures, used personal soap instead of facility-provided soap, and did not follow the correct sequence for catheter care. Interviews revealed inconsistencies in training and adherence to the facility's policy, contributing to the deficiency.
A resident with paranoid schizophrenia and bipolar disorder was found with shaving razors at their bedside, despite requiring assistance with daily living activities. Staff reported that the resident frequently obtains razors from central supply and brings them to their room, necessitating regular checks to remove such items. The facility's policy on hazardous equipment was not adequately followed, compromising resident safety.
A resident's nebulizer and oxygen tubing were found unprotected on the bedside table, violating infection control standards. The resident, with chronic respiratory conditions, had a care plan requiring respiratory treatments. A nurse confirmed the supplies should have been stored in a protective bag, as per facility policy.
Oxygen Therapy Not Delivered at Ordered Flow Rates
Penalty
Summary
The facility failed to ensure oxygen therapy was delivered as prescribed for three residents receiving oxygen. During observations, Resident #19 was seen in bed with oxygen running at 1.5 LPM on one occasion and at 2 LPM on later observations via nasal cannula, while the physician's order was for oxygen at 2 LPM via nasal cannula as needed for shortness of breath. Resident #19's record showed diagnoses including acute respiratory failure with hypoxia and COPD, and care plans directed staff to provide oxygen via nasal cannula as ordered and monitor for breathing difficulty. Resident #28 was observed in bed awake with oxygen running at 2 LPM via nasal cannula, including when a family member was present, while the physician's order was for oxygen at 3 LPM via nasal cannula, titrate to 5 L to keep saturation above 93%. Resident #28's record included acute respiratory failure with hypoxia, dependence for care, shortness of breath when lying flat, and care plan interventions for oxygen at 3 LPM via nasal cannula and monitoring for respiratory changes. Resident #28 was discharged on 05/19/2026. Resident #98 was observed in bed awake, then with eyes closed, and later asleep, with oxygen via nasal cannula running at 2.5 LPM during all observations, while the physician's order was for oxygen at 2 LPM via nasal cannula as needed for shortness of breath. Resident #98's record included a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, dependence for care, and shortness of breath when lying flat. Staff interviews stated they checked vital signs and verified physician orders against the oxygen flow rate on the concentrators, and the facility policy stated oxygen administration should be provided according to physician orders.
Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse. The incident involved a mental health technician who, according to multiple interviews and a now-overwritten video recording, engaged in rough physical handling of a resident on the facility's patio. The resident, who had diagnoses including dementia, psychosis, depression, and a history of falls, was moderately cognitively impaired but independent in activities of daily living. During the incident, the staff member pulled the resident out of a chair, and after a series of escalating interactions, the resident fell to the floor and was subsequently dragged or escorted to their room by the staff member. The resident sustained physical injuries, including bruises on the left knee and right forearm, and reported pain in the left knee. A physical assessment was performed, and the resident was found to be upset and yelling after the incident. The event was initially reported by another resident to the unit manager, who then assessed the resident and escalated the report to facility leadership. The incident was corroborated by interviews with the unit manager, DON, administrator, and social services director, all of whom reviewed the available evidence and confirmed the staff member's actions as physical abuse. The facility's own policies require staff to be able to identify and prevent abuse, but in this case, the staff member's actions were not reported by the perpetrator and only came to light through a third-party report. The incident was verified through internal investigation and interviews, and the staff member involved was found to have acted in a manner that was rough and unnecessary, resulting in physical harm to the resident.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/ N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and appropriate actions will be taken as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and any appropriate actions will be implemented as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025
Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse as required by federal regulations. The incident involved a mental health technician who, according to multiple interviews and a review of video footage, roughly grabbed a resident by the arm and pulled them out of a chair on the patio. The resident, who had diagnoses including dementia, psychosis, depression, and mobility difficulties, subsequently fell to the floor and was then dragged or escorted to their room by the staff member. The resident sustained bruises and reported pain, though they refused pain medication. The incident was not reported by the staff member involved, and there were no other staff present at the time. The resident's care plan indicated a history of behavioral issues, such as spitting at staff and attempting to hit staff with a shoe, with interventions in place to maintain a safe distance during episodes of aggression. Despite these interventions, the staff member engaged physically with the resident in a manner that was described by facility leadership as rough and unnecessary. The event was witnessed by another resident, who reported it to the unit manager. The unit manager then assessed the resident and found physical injuries consistent with the reported incident. The facility's policy required all employees, volunteers, and contractors to be able to identify and prevent abuse. However, the staff member's actions, as corroborated by interviews with the unit manager, DON, administrator, and a DCF investigator, constituted physical abuse. The incident was verified through internal investigation and review of available video footage, which was later recorded over. The abuse was reported to the appropriate authorities, and the facility confirmed the occurrence of physical abuse following their investigation.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated and appropriate actions will be taken, as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated and any appropriate actions will be implemented, as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025
Unattended Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and confirmed with the nearest room that the assigned nurse was not present. Approximately ten minutes later, a wound care nurse returned to the cart and acknowledged that it should have been locked when unattended, explaining that the cart was left unlocked by mistake while assisting a resident. Further interviews with the Director of Nursing confirmed that facility protocol requires medication carts to be locked when not attended. Review of the facility's policy on Medication Labeling and Storage also states that all medications and biologicals must be stored in locked compartments accessible only to authorized personnel. At the time of the survey, there were 131 residents in the facility.
Plan Of Correction
Citation: F580 (D/N199-Class: Iif, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Following this, audits will be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The findings of audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025 --- F761 (D/N95-Class: III, Isolated) On 06/17/2025, Staff A locked the medication/treatment cart after an interview with the surveyor. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents who have the potential to be affected by this deficient practice. On 6/22/2025, the Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. Frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025
Failure to Notify Family of Change in Resident Condition After Fall
Penalty
Summary
The facility failed to meet licensure requirements regarding the right of residents to be informed of their medical condition and changes in care. Specifically, staff did not notify the family or representative of a resident who experienced a fall. Documentation showed that after the resident was found on the floor, the medical doctor was notified, but there was no next of kin or responsible party listed to be notified, and no progress note indicated that any family notification occurred. The resident involved had a history of impaired gait, lack of coordination, seizures, and severe cognitive impairment. The care plan identified the resident as high risk for falls and included interventions to prevent such incidents. Despite these precautions, the resident experienced a fall, and the facility's policy required both the attending physician and family to be notified after such events. However, the demographic and event records indicated that no responsible party was assigned or notified at the time of the incident. Interviews with facility staff confirmed that the process for notifying family members was not followed in this case. The Admission Coordinator stated that emergency contact information is typically collected prior to admission, and the DON explained that the assigned nurse is responsible for notifying the first contact listed. However, in this instance, there was no documentation of family notification, and the nurse involved was no longer employed at the facility. The facility's policy on falls also required family notification, which was not documented as having occurred.
Plan Of Correction
N0199 Citation: F580 (D/N199-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly to ensure that the resident's responsible party/emergency contact, if any, was notified of the treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. --- practice. On 6/22/2025, Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 06/18/2025, Assistant Director of Nursing, provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. Frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025
Failure to Notify Family/Representative of Resident Fall
Penalty
Summary
Facility staff failed to notify a resident's family or representative of a change in condition, specifically following a fall incident. The resident, who was severely cognitively impaired and at high risk for falls due to diagnoses including impaired gait, seizure disorder, and lack of coordination, was found on the floor. The progress note documented that the medical doctor was notified, but no next of kin or responsible party was listed or notified at the time of the incident. Review of the resident's records showed that the demographic sheet, which should include emergency contact information, was created prior to admission. However, both the progress note and the fall event report indicated that no responsible party was assigned or notified after the fall. The facility's policy required staff to notify the resident's attending physician and family in an appropriate time frame after a fall, but this was not documented as having occurred. Interviews with facility staff confirmed that the process for notification involved contacting the first listed emergency contact multiple times, and moving to the next contact if necessary, unless otherwise specified. Despite this procedure, there was no documentation that the family or representative was informed of the fall, and the nurse responsible for the note was no longer employed at the facility. This lack of notification and documentation led to the cited deficiency.
Plan Of Correction
Citation: F580 (D/N199-Class: Iif, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary; and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025. The audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective action(s) will be monitored to ensure the deficient practice will not recur.
Unattended Unlocked Medication Cart Observed
Penalty
Summary
A deficiency occurred when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and, upon inquiry, found that the assigned nurse was inside a resident's room. The nurse, identified as a wound care nurse, acknowledged that the cart should always be locked when unattended and admitted to leaving it unlocked by mistake while assisting a resident. The facility's policy requires all medications and biologicals to be stored in locked compartments with access limited to authorized personnel. The observation and subsequent interviews confirmed that the cart was not secured as required, resulting in a failure to properly store medications in accordance with federal regulations. There were 131 residents in the facility at the time of the survey.
Plan Of Correction
Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Citation: F580 (D/ N199-Class: III, Isolated). Corrective actions will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving Resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the treatment change. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025. F0761 practice. On 6/22/2025, the Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing, provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025.
Deficient Catheter Care Practices Observed
Penalty
Summary
The facility failed to provide proper catheter care according to professional standards for two residents with indwelling urinary catheters. During observations, it was noted that staff did not perform hand hygiene before starting the catheter care procedure. For Resident #2, the CNA used the resident's personal soap instead of the facility-approved soap and did not follow the correct sequence for cleaning the perineal area and catheter. Similarly, for Resident #3, the CNA did not change washcloths between cleaning different areas, which is against the facility's policy. Both residents had clinical diagnoses that included urinary tract infections and required indwelling urinary catheters due to obstructive uropathy. The care plans for both residents included interventions to prevent infections, such as covering the urinary drainage bag and observing for signs of infection. However, the staff did not adhere to these protocols during the observed catheter care procedures. Interviews with staff revealed inconsistencies in training and adherence to the facility's catheter care policy. Some staff members reported receiving regular in-service training, while others stated they had not received any training on catheter care. The Infection Preventionist and Director of Nursing highlighted the importance of using the facility's soap and proper hand hygiene to prevent infections, but these practices were not consistently followed during the observed procedures.
Inadequate Infection Control in Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during the care of indwelling urinary catheters for two residents, leading to an increased risk of urinary tract infections (UTIs). During observations, staff members did not perform hand hygiene before starting catheter care procedures. Specifically, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) were observed not washing their hands before beginning the procedure for Resident #2. Additionally, the CNA used a personal soap instead of the facility-provided soap, and the catheter care was not performed in the correct sequence as per the facility's policy. For Resident #3, similar deficiencies were noted. Staff members failed to perform hand hygiene before starting the procedure, and the CNA did not change washcloths between cleaning different areas, which is against the facility's policy. The facility's policy requires using a clean washcloth for each cleansing stroke and using the facility-approved soap, which was not adhered to during the observed care. Interviews with staff revealed inconsistencies in training and adherence to the facility's catheter care policy. One CNA reported not receiving in-service training on catheter care, while others mentioned receiving monthly training. The Infection Preventionist and Director of Nursing highlighted the importance of using facility-provided soap and proper hand hygiene, which were not followed during the observed procedures. These lapses in protocol contributed to the facility's failure to reduce the risk of UTIs for the residents involved.
Resident Safety Compromised by Access to Shaving Razors
Penalty
Summary
The facility failed to ensure the safety of a vulnerable resident by allowing disposable shaving razors to be accessible at the resident's bedside. The resident, who has a history of paranoid schizophrenia and bipolar disorder, was observed with shaving razors on their bedside table on multiple occasions. Despite being cognitively intact, the resident requires partial moderate assistance for activities of daily living due to various medical conditions, including altered mental status and schizophrenia. The care plan for the resident indicates a self-care deficit and the need for assistance with activities of daily living. Interviews with facility staff revealed that the resident frequently obtains razors from the central supply and brings them to their room. A CNA reported that the resident loves to shave himself and is supervised during shaving, but he often manages to acquire razors and keep them in his room. The LPN confirmed that the resident is known to collect various items and that staff regularly check his room to remove inappropriate items. The facility's policy on hazardous areas and equipment emphasizes the need to address such hazards to ensure resident safety, yet the presence of razors in the resident's room indicates a lapse in adherence to this policy.
Infection Control Deficiency: Unprotected Respiratory Equipment
Penalty
Summary
The facility failed to adhere to infection control standards for one resident, as observed during a survey. The deficiency was identified when the nebulizer and oxygen tubing of a resident with chronic respiratory conditions were found unprotected on the bedside table. This observation was made while the resident was asleep, indicating a lapse in maintaining the cleanliness and safety of respiratory equipment. The resident, who was cognitively intact, had a history of chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). The resident's care plan included administering respiratory treatments and maintaining a patent airway. Despite these requirements, the nebulizer and tubing were not stored in a protective bag as per the facility's infection prevention and control policy. A registered nurse confirmed the oversight, stating that the respiratory supplies should have been stored in a bag with the date of the last change.
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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 North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Center For Rehabilitation And Healing | 0.1 mi | ★★★★★ | 0 | 0 |
| Claridge House Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 6 | 0 |
| Pines Nursing Home | 0.9 mi | ★★★★★ | 0 | 0 |
| Villa Maria Nursing Center | 1 mi | ★★★★★ | 4 | 2 |
| North Dade Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 9 | 0 |
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