Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gainesville Health And Rehabilitation during CMS and state inspections, most recent first.
Kitchen dishwashing area equipment and flooring were not maintained in safe working condition. A garbage disposal was non-functional and leaking water, causing standing water across the work area, and multiple floor tiles were lifted, uneven, or missing with exposed subfloor. Kitchen staff reported the condition had been ongoing for months, the MDS and admin were aware, and the maintenance log showed no active or pending work order for the leaking disposal or damaged flooring.
Two residents with multiple comorbidities experienced significant weight loss when the facility failed to implement and follow up on RD assessments and recommendations. For one resident, the RD documented substantial weight decline, recommended appetite stimulation with Remeron, and noted variable intake despite supplements, but nursing staff did not communicate these recommendations or the weight loss to the physician or the resident’s representative, and no corresponding orders were obtained. For the second resident, who had documented weight loss and an RD recommendation to increase nutritional supplements, there were no subsequent RD reassessments despite ongoing weight decline, and the RD and DON confirmed that continued weight loss was not communicated to dietary, and monitoring processes did not identify the need for further intervention, contrary to the facility’s nutritional management policy.
The facility failed to notify representatives and physicians of significant weight loss in two residents, despite a policy requiring prompt communication of changes in condition and completion of an SBER change-in-condition evaluation. One resident with multiple chronic conditions, including dementia and diabetes, experienced more than a 12% weight loss over several months without documented notification to the representative or physician, and the representative reported not being informed of the weight loss or related interventions. Another resident with extensive cardiovascular, neurologic, and psychiatric diagnoses, including CHF, vascular dementia, and mild protein-calorie malnutrition, also lost more than 12% of body weight over six months, with no documented family or physician notification. An LPN acknowledged that the physician and representative had not been contacted, the RD stated that notification was a nursing responsibility, and the DON confirmed the absence of documentation of required notifications.
Surveyors found that the facility failed to maintain a safe, clean, and comfortable environment in multiple hallways and rooms. Strong urine odors were present throughout two hallways and in all rooms toured on one hallway, even though residents were observed to be clean and dry. Floors in several rooms had dried, sticky residue and multiple stains, vents and grates had thick dust buildup, and debris such as straws and cup lids was found under beds. Handrails had missing paint with wet underlying paint, shower rooms had thick brown substances in the corners, and three of four hallways had missing or unsecured flooring pieces that could be lifted easily. A housekeeping closet lacked a doorknob. The NHA, DON, and Assistant Maintenance Director acknowledged these environmental issues, which did not align with the facility’s policy requiring a safe, functional, sanitary, and comfortable interior.
Surveyors found that several residents did not have accurate assessments reflecting their current diagnoses and treatments, including psychiatric conditions, skin disorders, dialysis, and CPAP use. LPNs responsible for MDS completion either omitted or failed to properly code these conditions, sometimes due to uncertainty or human error, resulting in incomplete documentation of residents' health status.
Two dependent residents were assisted with breakfast by a CNA who stood between their beds and alternated feeding them, rather than providing individualized attention. The CNA reported being unsure of the correct feeding method due to inexperience. Facility policy requires residents to be treated with respect and dignity.
A resident with cardiac and anemia diagnoses was observed self-administering oxygen therapy without a physician's order, and staff were unaware of the resident's use of oxygen. Facility policy requires a physician's order for oxygen administration except in emergencies, but no such order was present in the medical record.
Surveyors found that drugs and biologicals were not properly labeled or securely stored, including instances where a resident had unidentifiable pills and an unlabeled cream at bedside, another had a prescription ointment left out, and a third kept prescription medications at bedside without proper orders. Expired and undated medications were also found on a medication cart, and staff confirmed these practices were not in line with facility policy.
A resident's medical record contained conflicting information regarding code status, with some documents indicating full code and others indicating DNR. The resident did not recall discussing DNR status, and the DON confirmed the resident was full code with no DNR order on file, attributing the error to social services. Facility policy for verifying and updating code status was not properly followed.
A facility failed to follow professional standards for tube feeding administration for a resident with multiple diagnoses, including cerebral infarction and dysphagia. A CNA improperly paused and restarted the feeding pump, a task reserved for nurses, and both the CNA and an LPN provided care without adhering to universal precautions, such as wearing gowns, gloves, or performing hand hygiene. The facility's policy mandates that only nurses handle feeding pumps and that universal precautions be followed.
A long-term care facility failed to adhere to infection control protocols for two residents on Enhanced Barrier Precautions. Staff did not perform hand hygiene or use appropriate PPE, such as gowns and gloves, during high-contact activities with residents who had feeding tubes and indwelling catheters. Interviews revealed a misunderstanding of the facility's policy, which aligns with CDC guidelines requiring PPE for high-contact activities to prevent the spread of infections.
The facility failed to provide written bed hold notices to residents or their representatives upon hospital transfer. Three residents, each with different medical conditions, were transferred to a hospital without receiving the required notification. Interviews with facility staff confirmed the absence of a process for issuing these notices, despite policy requirements.
Kitchen Dishwashing Area Not Maintained in Safe Condition
Penalty
Summary
The facility failed to ensure essential equipment and building components were maintained in a safe operating condition in the kitchen dishwashing area. During observation, the garbage disposal unit was non-functional and actively leaking water, with a continuous flow of water creating standing water across the floor in the immediate work area. The flooring in the same area had multiple lifted and uneven tiles, with sections missing and the underlying subfloor/concrete exposed. Staff interviews confirmed the condition had been ongoing for months. A kitchen aide stated the sink, garbage disposal, and standing water had been that way since she started about 4 months earlier, and another kitchen aide said the area had been broken and leaking since he started about 4 months earlier. A third kitchen aide stated the area had been leaking or broken since the middle of 2025 and described the broken disposal as being emptied manually, with food remaining in the unit. The maintenance director stated he was aware of the broken sink, garbage disposal, and standing water, and the administrator stated he had known about the concern in the kitchen for about 2 months. The facility's TELS maintenance log showed no active or pending work order for the leaking garbage disposal or damaged flooring, and the facility policy stated the environment would be equipped and maintained to protect the health and safety of residents, personnel, and the public.
Failure to Implement Dietician Recommendations and Monitor Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status for two residents experiencing significant weight loss by not following or acting upon dietician assessments and recommendations. For the first resident, who had multiple diagnoses including dementia, hypertension, anemia, type 2 diabetes, hyperlipidemia, hypothyroidism, and vitamin deficiencies, serial weights showed a decline from 106.2 pounds to 93.2 pounds over several months, representing a significant weight loss of over 10%. The registered dietician (RD) documented that the resident was on a regular diet with milkshakes three times daily and Med Pass, with variable intake, and identified a significant 3‑month weight loss likely related to worsening dementia. The RD recommended considering Remeron to stimulate appetite and noted the need to encourage meals, snacks, supplements, and fluids. Despite these documented recommendations on multiple RD weight notes, the resident’s medical record contained no physician orders for Remeron during the relevant periods. The RD stated in interview that she had recommended Remeron, placed the recommendation in a binder at the nurses’ station, and had spoken with the unit manager and DON, but the recommendation was not conveyed to the physician and was not acknowledged in the communication book. The RD indicated she does not write orders or contact the family or physician, and that this responsibility lies with nursing. An LPN confirmed that nursing did not communicate the RD’s Remeron recommendation or the weight loss to the physician or the resident’s representative, and that staff had incorrectly assumed the RD could write orders. For the second resident, who had extensive diagnoses including cerebral infarction, peripheral vascular disease, CHF, vascular dementia, mood disorders, insomnia, benign prostatic hyperplasia, neuropathy, and mild protein‑calorie malnutrition, weights showed a decline from 185.4 pounds to 163.1 pounds over six months, a 12.3% loss. A physician order had been written for an in‑house dietician consult for weight loss, and the RD completed a weight note documenting significant 1‑ and 6‑month weight loss, variable intake, and current use of Ensure Plus twice daily. The RD recommended increasing Ensure Plus to three times daily and noted the need to monitor intake, weight trends, and labs. However, there were no additional RD assessments in the record after this note, and the RD acknowledged she had not seen the resident again, was unaware of the continued weight loss, and lacked access to targeted weight‑loss reports. The DON stated there should have been dietary reassessments and that nurses and unit managers should have notified the RD of the continued weight loss, but there was no evidence this occurred, contrary to the facility’s nutritional management policy requiring systematic assessment, individualized interventions, monitoring, and physician notification of significant weight changes.
Failure to Notify Representatives and Physicians of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly inform resident representatives and physicians of significant changes in condition, specifically substantial weight loss, for two residents. Resident #1 had multiple diagnoses including dementia with mood disturbance, bilateral knee pain, vitamin B and D deficiencies, essential hypertension, anemia, type 2 diabetes mellitus without complications, hyperlipidemia, and hypothyroidism. Weight records showed a decline from 106.2 pounds on 10/6/2025 to 93.2 pounds on 3/2/2026, a 12.24% weight loss. Review of nursing progress notes from October 1, 2025 through March 2, 2026 revealed no documentation that the resident’s representative or physician was notified of this change in condition. The resident’s representative reported not being informed of the weight loss, any interventions, or dietician involvement, and an LPN acknowledged that the physician and representative had not been contacted or that such communication had been documented. Resident #2 had diagnoses including cerebral infarction, peripheral vascular disease, history of falling, hyperlipidemia, essential primary hypertension, unspecified systolic congestive heart failure, urinary retention, pseudobulbar effect, vitamin D deficiency, major depressive disorder, primary insomnia, bipolar disorder, benign prostatic hyperplasia, atherosclerosis of other arteries, idiopathic peripheral autonomic neuropathy, vascular dementia, and mild protein calorie malnutrition. Weight records showed a decline from 185.4 pounds on 10/3/2025 to 163.1 pounds on 3/3/2026, a 12.3% weight loss over six months. The Registered Dietician stated that notifying families and physicians about weight loss was the responsibility of nursing staff. The DON confirmed there was no documentation of family or physician notification for these significant weight losses, despite a facility policy titled “Change in Condition Process” requiring prompt notification of the resident, physician, and representative when there is a change requiring such notification, including changes necessitating significant alteration of treatment and completion of an SBER Change in Condition evaluation in the electronic medical record.
Failure to Maintain Clean, Safe, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide housekeeping and maintenance services necessary to ensure a safe, clean, comfortable, and homelike environment in multiple hallways and resident rooms. During an initial tour, a strong urine odor was noted throughout the 200 and 300 hallways, including common areas, and all rooms toured in the 300 hallway had a pronounced urine odor despite residents being observed as clean, dry, and appropriately dressed. In the 200 hallway, two rooms had floor grates with thick dust buildup, and several rooms had floors with dried, sticky residue. In the 300 hallway, the linen closet door vent had a heavy layer of dust. Several rooms had sticky floors with multiple dried stains, scuffed walls, missing paint, and significant dust and debris, including straws and cup lids, under the beds. Additional environmental issues were observed in common areas and service spaces. The 300 hallway handrail had missing paint beneath a hand sanitizer dispenser, and the underlying paint was wet and easily scraped off. Shower rooms in two hallways had thick brown substances in the corners that could be easily removed by hand. Three of the four hallways toured had missing or unsecured pieces of flooring that could be lifted without effort, and one housekeeping closet was missing a doorknob. The Nursing Home Administrator and DON acknowledged the strong urine odor, sticky residue and dried stains on floors, dust and debris under beds, dust accumulation on vents and grates, and missing or loose flooring. The Assistant Maintenance Director acknowledged chipped or missing flooring and areas no longer properly adhered. These conditions were inconsistent with the facility’s own policy, which requires maintaining a safe, functional, sanitary, and comfortable environment and providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Inaccurate Resident Assessments for Diagnoses and Treatments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents in areas including psychiatric diagnosis, skin conditions, dialysis treatment, and respiratory care. For one resident with a documented history of schizophrenia and a current prescription for Aripiprazole, the Minimum Data Set (MDS) admission assessment did not record an active diagnosis of schizophrenia, despite supporting documentation from the discharging hospital and physician orders. Staff responsible for MDS completion expressed uncertainty about the requirements for documenting this diagnosis. Another resident with a history of skin disorders and a dermatologist-confirmed diagnosis of Prurigo Nodularis, presenting with visible rashes and lesions, was not coded for any skin problems in the MDS quarterly assessment. Staff stated they did not code for rashes and were unaware of the lesions. Additionally, a resident with end stage renal disease and active physician orders for dialysis was not documented as receiving dialysis treatments in the MDS quarterly assessment, which staff attributed to human error. Similarly, a resident with chronic respiratory failure and obstructive sleep apnea, who had a physician order for nightly CPAP use, was not documented as using CPAP in the MDS. Staff again cited human error for the omission. These findings were based on interviews, record reviews, and direct observations, demonstrating a pattern of incomplete or inaccurate resident assessments.
Failure to Promote Dignified Dining Experience During Resident Feeding
Penalty
Summary
Staff failed to promote a dignified and homelike dining experience for two dependent residents during breakfast. Both residents, who were assessed as dependent on staff for eating per their Minimum Data Set (MDS) quarterly assessments, were observed in bed with breakfast trays on their bedside tables. A CNA was seen standing between the two residents, alternating assistance by feeding each a spoonful of breakfast in turn, rather than providing individualized attention. During an interview, the CNA stated uncertainty about the correct feeding procedure, citing limited experience as a CNA. The facility's policy on resident rights, last reviewed on 2/26/2025, requires residents to be treated with respect and dignity.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, atherosclerotic heart disease, and anemia was observed multiple times with oxygen tubing and an oxygen concentrator in their room, but without a physician's order for oxygen therapy. The resident reported self-administering oxygen as needed when experiencing shortness of breath, and stated that the oxygen machine was already set to 4 liters. Despite these observations, there was no documentation of a physician's order for oxygen in the resident's medical record. The Assistant Director of Nursing confirmed unawareness of the resident's use of oxygen and acknowledged that a physician's order is required for PRN oxygen use. Facility policy also specifies that oxygen must be administered under a physician's order except in emergencies, with orders to be obtained as soon as practicable. The lack of a physician's order for the resident's ongoing use of oxygen therapy was inconsistent with professional standards of practice and facility policy.
Failure to Properly Label and Secure Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as evidenced by multiple observations and interviews. In one instance, unidentifiable pills and an unlabeled cream-like substance were found in a resident's room, left on bedside tables for extended periods. The resident confirmed that staff routinely left medications at the bedside for later consumption, and staff interviews acknowledged this was not the facility's expectation. Additionally, another resident had a tube of Aquaphor with a prescription label left on the bedside table, and a third resident kept prescription medications, including Trelegy and Triamcinolone, at the bedside without proper orders or security. The DON confirmed that no residents were authorized to have medications at bedside. Further deficiencies were identified during a review of a medication cart, where expired Folic Acid and undated Latanoprost eye drops were found. Staff interviews confirmed that all resident-specific bottles should be dated and expired medications should not be present on the cart. Facility policy requires all medications to be stored in locked compartments and under direct observation during medication passes, which was not adhered to in these instances. The findings demonstrate a failure to comply with labeling and storage requirements for drugs and biologicals.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that the medical records for a resident were accurate and complete regarding advanced directives. The resident's admission record and physician's order both indicated a full code status, while the social services assessment and care plan documented a Do Not Resuscitate (DNR) order. This inconsistency in documentation led to conflicting information about the resident's code status across different parts of the medical record. During interviews, the resident stated not recalling any discussion about DNR status, and the Director of Nursing confirmed that the resident was a full code with no DNR order on file. The Director also acknowledged that the assessment and care plan were inaccurate due to an error by social services. The facility's policy requires code status to be verified upon admission and reviewed regularly, but this process was not properly followed for the resident in question.
Failure to Follow Professional Standards in Tube Feeding Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering tube feedings for a resident diagnosed with cerebral infarction, dysphagia, aphasia, and major depressive disorder. The resident was prescribed continuous enteral feeding with Jevity via a feeding pump. During an observation, it was noted that the feeding pump was on hold, and the feeding was not running. A Certified Nursing Assistant (CNA) was observed handling the feeding pump, which is against the facility's policy that only nurses should manage the feeding pump. The CNA admitted to pausing the feeding pump during care and restarting it afterward, a practice she had been following without being instructed otherwise. Additionally, the CNA and a Licensed Practical Nurse (LPN) were observed providing care to the resident without wearing gowns or gloves and without performing hand hygiene, which violates universal precautions and clean technique protocols. The Director of Nursing confirmed that CNAs should not handle the feeding pump and should seek assistance from a nurse to pause and restart the feeding. The facility's policy on enteral feeding emphasizes the use of universal precautions and clean techniques, which were not followed in this instance.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to prevent the possible spread of infection by not adhering to proper hand hygiene and personal protective equipment (PPE) protocols for two residents on Enhanced Barrier Precautions (EBP). Resident #7, who was admitted with conditions including cerebral infarction, dysphagia, aphasia, and major depressive disorder, was observed without EBP supplies such as gowns near his room. Staff B, a Certified Nursing Assistant (CNA), and Staff C, a Licensed Practical Nurse (LPN), entered Resident #7's room without performing hand hygiene or donning gowns and gloves. They assisted in repositioning the resident in bed and handling his feeding tube without the necessary PPE, subsequently failing to perform hand hygiene after exiting the room. Resident #9, admitted with diagnoses including neuromuscular dysfunction of the bladder, cervical spinal cord injury, epilepsy, Type 2 Diabetes Mellitus, and viral hepatitis B, was also on EBP due to an indwelling catheter. Staff D, a CNA, and Staff E, an Occupational Therapist (OT), were observed assisting Resident #9 without wearing gowns, only gloves, and failing to perform hand hygiene before and after care activities. Staff D handled the resident's urinary catheter and personal items without changing gloves or performing hand hygiene, while Staff E did not perform hand hygiene after removing gloves and exiting the room. Interviews with the staff revealed a lack of adherence to the facility's EBP policy, which requires gowns and gloves for high-contact activities such as transferring, providing hygiene, and handling devices like feeding tubes and catheters. The Director of Nursing (DON) confirmed the policy but indicated a misunderstanding of when gowns are necessary, believing they were only required if the resident had an actual infection. The facility's policies and CDC guidelines clearly state the need for PPE during high-contact activities to prevent the spread of multidrug-resistant organisms.
Failure to Provide Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, as required. This deficiency was identified for three residents who were transferred to a hospital for various medical reasons. Resident #1, diagnosed with Huntington's disease and other conditions, was transferred for a psychiatric evaluation after becoming combative. Resident #2, with conditions including heart failure and diabetes, was transferred for a possible blood transfusion due to low hemoglobin levels. Resident #3, suffering from systemic lupus erythematosus and other ailments, was transferred due to chest pain. In all cases, there was no documentation of a written bed hold notice being provided. Interviews with the facility's Administrator and Director of Nursing revealed that the facility considered residents discharged upon hospital transfer and did not have a process for providing bed hold notifications. The facility's policy required providing a notice of transfer and the bed hold policy to residents and their representatives, but this was not followed. The facility's failure to provide these notices was confirmed by the absence of documentation and the statements from the facility staff.
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What surveyors actually found near you
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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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Meadows Healthcare & Rehabilitation Center | 1.5 mi | ★★★★★ | 30 | 0 |
| Palm Garden Of Gainesville | 1.5 mi | ★★★★★ | 0 | 0 |
| Plaza Health And Rehab | 1.6 mi | ★★★★★ | 19 | 0 |
| Oak Hammock At The University Of Florida Inc | 2.5 mi | ★★★★★ | 0 | 0 |
| Aviata At North Florida | 2.7 mi | ★★★★★ | 23 | 3 |
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