Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gulfside Health And Rehabilitation Center during CMS and state inspections, most recent first.
Dish Machine Failed to Reach Required Temperatures: The kitchen’s low-temperature dishwashing machine did not reach the manufacturer-required wash and rinse temperatures of at least 120 F during observed cycles. A Dietary Aide and the Dietary Manager repeatedly ran the machine and pressed buttons they believed would help, but the wash and rinse temperatures stayed at 110 F, and the sanitizer step could not be demonstrated. The DOM later stated the thermometer was not working and that no prior work order had been entered before the observation.
Failure to Document Resident Council Concerns as Grievances: Residents with intact cognition reported unresolved concerns about meal quality and portion sizes, dining room closure, and delayed call light response times during council meetings. Although these issues were documented in council minutes, they were not entered into the grievance log, and no documented investigations, follow-up, or resolutions were recorded; interviews showed the AD, RD, and SSD had inconsistent handling of the concerns.
Unsafe and Unclean Resident Environment: Surveyors observed black bio-growth in the north unit shower room, heavy dust on a fan between resident beds, missing floor tiles, rust and buildup on shower/tub drains and showerheads, uncovered plungers, and dirty or damaged tubs, blinds, and wall surfaces in multiple resident rooms. On the smoking patio, only two of four fans were working, and facility leadership acknowledged cleaning, maintenance, and documentation issues across the affected areas.
Catheter drainage bag left on floor: A resident with a suprapubic indwelling urinary catheter was observed in bed with the drainage bag and tubing touching the floor on two occasions. The resident had diagnoses including MSSA infection and neurogenic bladder, and the care plan directed staff to keep the catheter below the bladder but off the floor as able. An LPN/UM/IP stated the bag should be off the floor because it is dirty and contact with the floor may cause infection; facility policy required daily catheter care and proper tubing placement for gravity drainage.
Pest control was not maintained in one unit after surveyors observed a roach in a resident room and multiple flies in another room, including one landing on a resident's face while staff only fanned at the insect. Staff and residents reported seeing roaches and flies, but the facility could not produce complete, facility-wide pest logs, and vendor records documented repeated pest activity in resident and staff areas, with some treatment delayed pending corporate approval.
A resident was served the wrong lunch tray and initially received an alternate meal that included an ingredient she was allergic to, rather than the primary meal she expected. She reported repeated problems with meal delivery, including missing meals and incorrect items, and staff could not explain why the tray mismatch occurred. The resident later received the primary meal, and records showed an egg allergy, an EpiPen order, and an order to check trays against meal tickets before delivery.
Failure to Maintain Privacy During ADL Care: A CNA was observed providing ADL care to a resident while his pants were down and his buttocks were exposed to the hallway with the room door fully open. The CNA said the door was left open because the resident was a fall risk, but the care plan did not include that intervention. The resident had diagnoses including autonomic nervous system disorder, generalized muscle weakness, TIA history, cerebral infarction without residual deficits, right eye blindness, and falls history, and his BIMS score indicated intact cognition.
Failure to Notify Residents Before Temporary Room Displacement: Two residents were temporarily moved or affected during deep cleaning and floor waxing without prior notice. One resident reported being relocated for 21 hours, with belongings left in the hallway and personal items stolen, while another resident said housekeeping entered without knocking and began cleaning without advance notice. Staff and the DON confirmed residents normally should receive advance notice, but it did not occur.
Failure to Follow Grievance Process for Missing Belongings: A cognitively intact resident reported missing personal items, including a mirror, body wash, and water, and said he had already raised the concern with Social Services and staff. The SSD confirmed she discussed the issue with the resident and that the NHA agreed to replace the items, but no grievance was filed and the facility did not follow its grievance procedure.
The facility failed to provide required transfer/discharge documentation and notifications for two residents transferred to the hospital. One resident with multiple serious diagnoses had no record of the bed hold policy, DNR/advance directives, current meds, reason for transfer, transfer time, receiving location, or Ombudsman notification, and staff reported there was no nursing documentation or evaluation. Another resident was sent to the ER after becoming lethargic and unresponsive with low O2 saturation, but the DON could not locate the AHCA hospital transfer form or bed hold policy required with the discharge paperwork.
Failure to follow PASRR Level II recommendations for two residents. One resident with serious mental illness diagnoses had a PASRR notice requiring Level II screening, but the record did not show the facility obtained the evaluation results or followed up with the state entity. Another resident with schizoaffective disorder, bipolar type, MDD, and anxiety had a PASRR recommendation for an additional Level II review if there was a significant change in mental status, while staff and the MDS coordinator described ongoing yelling, belligerence, and difficult-to-redirect behavior; the DON stated she believed follow-up was only for new diagnoses, not behaviors.
PASRR screening was not accurate for a resident whose record later included additional serious mental illness diagnoses. The SSD and DON stated PASRR is reviewed at admission and updated as needed, but the resident’s PASRR Level I was not reassessed after new diagnoses were added to the medical record. Facility policy required screening before admission and review when a significant change in status occurs.
Failure to revise care plan for behavioral expression: A resident with MDD, mood disorder, and anxiety was observed writing harmful political phrases on a cup and on the wall behind his bed. Staff acknowledged the behavior, and the SSD and MDS Coordinator confirmed the resident had behavior-related issues and should have had a behavior care plan, but the existing care plan did not address the observed conduct.
A resident with ESRD and dependence on renal dialysis missed multiple scheduled dialysis treatments because transportation did not arrive on time or was not arranged early enough for the resident’s chair time. Records showed repeated missed or refused dialysis appointments, while the transportation driver said he had never taken the resident to dialysis and the LPN/UM stated the driver was not at the facility early enough for the scheduled pickup.
Failure to Provide Trauma Informed Care for a Resident with PTSD: A resident with documented PTSD, depression, anxiety, and trauma history was observed trying to block out very loud housekeeping machines in the hallway. Her psych notes identified loud noises and unwanted physical touch as triggers, but the MDS, care plan, Resident Matrix, and staff interviews showed the PTSD diagnosis and triggers were not recognized or incorporated into care, and staff were unaware of the resident's trauma-related needs.
A resident with depression, bipolar disorder, anxiety, and a mood disorder was prescribed trazodone, oxcarbazepine, and divalproex sodium, but no side effect monitoring was documented in the MAR/TAR. The consultant pharmacist recommended adding side effect observations during MRR, and the VP of Clinical Operations/RN confirmed the recommendation was not implemented and there was no documentation that nursing or the DON addressed it.
Medication administration errors exceeded the allowed rate after surveyors observed 3 errors during 47 opportunities, resulting in a 6.38% error rate. An RN gave Midodrine despite BP being outside the ordered hold parameter and administered Metoprolol at the wrong dose, while an LPN gave a multivitamin with minerals instead of the ordered multivitamin adult oral tablet. The DON stated nurses were expected to follow medication orders.
Improperly labeled and undated medications were found in one medication cart during observation. An LPN found an undated albuterol inhaler, an open and undated fluticasone/salmeterol inhaler, and an open but undated Novolog FlexPen for three residents. The LPN said staff sometimes do not take time to add open and expiration dates, while the ADON and DON said the facility provides resources for dating opened insulin and inhaled medications.
Failure to Coordinate Follow-Up Dental Care: A cognitively intact resident with significant neurologic history had a prior partial tooth extraction and ongoing dental needs, but the scheduled oral surgery appointment was missed after it was set for the wrong day and then further disrupted by a location issue and language barrier at the dental office. The POA was not informed whether the appointment occurred, no follow-up dental appointment was documented, and the LPN/unit manager did not reschedule or coordinate with Social Services after learning the resident still needed oral surgery and had insurance complications.
A resident who preferred to eat in her room did not receive her scheduled lunch tray, despite asking an aide and an LPN twice for the meal. Staff later confirmed the tray was not delivered, possibly being sent to the wrong location and left in the dining room, and the Dietary Manager had no documentation showing where it went. The resident, who had PTSD, major depression, insomnia, and anxiety, said she would have eaten the facility meal if it had been provided.
A resident council reported that bedtime PB&J sandwiches were thin half sandwiches with little peanut butter and jelly, and the DM confirmed staff were making them with only 1 tbsp each of peanut butter and jelly instead of the full recipe requiring 3 1/2 tbsp peanut butter, 1 1/4 tbsp jelly, and 2 slices of bread. During lunch service, cartons of milk were placed on the steam table counter near hot foods without ice or another cooling method, and a tested carton read 44 degrees F, above the required 41 degrees F limit.
A long-term care facility failed to provide adequate supervision and fall prevention for several residents, leading to multiple unwitnessed falls and injuries. Residents with severe cognitive impairments and high fall risks were not consistently monitored, and necessary safety interventions were not implemented. Documentation was incomplete, with missing neuro checks and post-fall reviews, and care plans were not updated to reflect necessary interventions, contributing to the continued risk of falls.
A resident with severe cognitive impairment experienced unwitnessed falls, resulting in significant facial injuries. Despite the severity, the incident was not reported as required. The resident was found with a laceration and swelling around the eye, and a CT scan revealed multiple facial fractures. The Nursing Home Administrator could not recall if the incident had been reported, and the facility's Reportable Event Tracking Log did not document the fall.
Dish Machine Failed to Reach Required Temperatures
Penalty
Summary
The facility failed to ensure the kitchen’s low-temperature dishwashing machine operated according to manufacturer specifications. During a kitchen tour, the Dietary Manager stated the machine required a wash cycle of at least 120 F, a rinse cycle of at least 120 F, and a chemical sanitizer reading between 50-100 ppm, and said maintenance normally maintained the machine. A Dietary Aide who had worked in the role for less than two weeks was operating the machine and was responsible for checking dish machine temperatures before each meal service. Both staff stated the machine was functioning properly and ready for use. During observed test cycles, the machine repeatedly failed to reach the required temperatures. After three empty cycles, a full wash cycle was run and both the wash and rinse temperatures reached only 110 F. Staff were instructed to press a prime button and later a black button on the machine, but repeated cycles continued to hold at 110 F. Because the machine did not reach temperature requirements, the sanitizer step was not demonstrated. The Dietary Manager stated she would enter a work order and believed the temperature gauge was not functioning properly. The Director of Maintenance later stated the original thermometer was not working at all, that he replaced it when the ordered part arrived two days later, and that there had been no prior work order before the observation. The Administrator provided the manufacturer’s manual, which states the minimum operating temperature is 120 F and instructs users to verify incoming water is at least 120 F.
Failure to Document Resident Council Concerns as Grievances
Penalty
Summary
The facility failed to ensure concerns voiced during resident council meetings were documented and processed as grievances in accordance with facility policy. During a resident council meeting on 6/8/26, four residents with intact cognition and BIMS scores of 15 reported ongoing unresolved concerns, including lack of grievance follow-through, the dining room closing after 4:30 p.m. without explanation, poor quality bedtime peanut butter and jelly sandwiches, reduced lunch portion sizes, and call light response times of 30 minutes to 1 hour during midnight and weekend shifts. The residents stated these concerns had been repeatedly raised in council meetings, but they had not received explanations or resolutions. Review of resident council minutes from 12/15/25, 1/19/26, 3/24/26, and 4/20/26 documented concerns such as lights not being answered on time, unsatisfactory lunch, night staff behavior and supervision concerns, shower and housekeeping issues, lack of coffee, call light issues, and dining room closure. Despite these concerns being voiced, none were logged as grievances, and no documented investigations, follow-up, or resolutions were recorded in the grievance log for 12/2025, 1/2026, 3/2026, or 4/2026. Interviews with the AD, RD, and SSD showed the AD took notes at council meetings and said grievance forms were available, the RD was unaware of the resident’s request for larger portions, and the SSD stated she documents grievances when received but did not review resident council minutes and was unaware the concerns had not been entered into the grievance log.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment and did not ensure equipment was properly maintained and functional in multiple areas of the building, including the smoking patio, the north unit shower room, and ten resident rooms on the north unit. Surveyors observed black bio-growth in the crevices and caulking around the shower floor in the north unit shower room. They also observed a standing fan between two resident beds with heavy dust and trapped particles, missing floor tiles near the fan, uncovered toilet plungers in bathrooms, bedpans with brown substance inside, rust stains over uncovered shower or tub drains, and rust and white buildup on showerheads. Additional observations included broken or missing room features such as missing tiles, dirty floors, broken blinds, missing wall paint, scratched or peeling paint, and dirty tubs. On the smoking patio, only two of four oscillating fans were working, and one fan required a pull cord while another was nonfunctional. During interviews, facility leadership acknowledged issues with cleaning, maintenance, and documentation of environmental projects, including that plungers should not be stored in resident bathrooms and that some rooms and tubs needed cleaning or repair. The facility's Environment of Care policy stated that residents would be provided a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services were necessary to maintain a sanitary, orderly, and comfortable interior.
Catheter drainage bag left on floor
Penalty
Summary
Infection control standards were not followed for a resident with a suprapubic indwelling urinary catheter when the catheter drainage bag and tubing were observed touching the floor while the resident was lying in bed. This was observed on two separate occasions, including one observation with a CNA present who stated her role was to empty the drainage bag and clip it back to the bed in the same position. The resident was admitted with diagnoses including methicillin susceptible staphylococcus aureus infection and neuromuscular dysfunction of the bladder, and the care plan identified a suprapubic indwelling urinary catheter with interventions to keep the catheter below the level of the bladder but off the floor as able. The resident’s physician orders included suprapubic catheter care every shift and monthly catheter bag changes. During interview, the LPN/unit manager/infection preventionist stated the catheter drainage bag should be off the floor when a resident is sitting in a chair or lying in bed, explaining that the floor is dirty and contact with the floor may cause an infection. The facility policy for indwelling catheters stated staff should provide daily catheter care or as ordered and ensure proper placement of catheter tubing to prevent kinking, excessive pulling, and allow gravity drainage.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an environment free of pests in one unit of two units observed. Surveyors observed a medium-sized brown roach crawling on the floor in one resident room and multiple flies in another resident room, including a fly landing on a resident's face. Staff were observed fanning at the insect, and no additional interventions were implemented at that time. During interviews, an LPN stated she had seen roaches in the facility, especially palmetto bugs, and a housekeeper reported seeing roaches sporadically in the facility. Two residents also reported seeing flies and roaches. Record review showed the facility could not provide pest-sighting logs consistent with a comprehensive, facility-wide monitoring system. The facility produced only two South unit pest sighting log sheets, with one sheet containing a single 2026 entry without a pest description or location, and the other sheet listing limited sightings on the North side. The pest control service agreement called for twice-monthly services covering cockroaches, flies, ants, rodents, and spiders, and service records documented repeated pest activity, including roach activity in a resident room, roaches in the south nurses' station and soiled utility room, roaches in a downstairs staff area, and reports of bed bugs in a resident room. The records also noted instances where recommended treatment was delayed pending corporate approval.
Meal Tray Served With Allergen Ingredient
Penalty
Summary
The facility failed to provide one resident with a meal free from ingredients the resident was allergic to during lunch service. On 6/10/2026, the resident received a tray in her room that contained the alternate meal instead of the primary meal she expected, and the meal ticket showed chicken, rice, peas, and a roll. The resident stated she did not order the alternate meal, believed the kitchen should have served the primary meal unless requested otherwise, and reported that the kitchen had been getting her meals wrong almost every day, including not providing a meal the prior day and not sending condiments for various items. The resident was observed telling an LPN that she did not want what was served and that kitchen staff would not answer the phone so she could choose the primary meal she should have received. By 12:39 p.m., she still had not been provided her primary lunch meal. At 1:53 p.m., she was given another tray with meatloaf, mashed potatoes, peas and carrots, and a roll, which she ate. Review of the meal tickets showed the first tray served was the alternate meal and listed an egg allergy, while the second ticket identified meatloaf as the meal choice. The resident's record showed she had a BIMS score of 15 and was not on a therapeutic or mechanically altered diet. Her physician's orders included an EpiPen for allergic reaction and an order to check all resident trays before lunch and dinner to ensure the food and ticket matched.
Failure to Maintain Privacy During ADL Care
Penalty
Summary
The facility failed to ensure ADL care was provided in a manner that maintained dignity and privacy for one resident. On 6/9/26 at 9:50 a.m., a CNA was observed providing ADL care to Resident #2 while the resident stood in the doorway of his room with his pants down and his buttocks exposed to the hallway. The resident’s door was fully open, and his exposed condition was visible from the hallway during the care activity. During interview, the CNA stated she left the door open because Resident #2 was a fall risk and she did not want him to fall during hygiene care after a bowel movement and urination. Record review showed Resident #2 was admitted and readmitted to the facility with diagnoses including disorder of autonomic nervous system, need for assistance with personal care, generalized muscle weakness, history of TIA, cerebral infarction without residual deficits, right eye blindness, and history of falls. A BIMS assessment showed a score of 13, indicating intact cognition. The care plan did not include any intervention directing that the door remain open during ADL care for fall risk precautions, and the ADL/incontinence care plans directed staff to provide privacy during care, encourage toileting, use incontinence products to maintain dignity, and assist with toileting at scheduled intervals. The LPN/UM stated staff are expected to close the door and privacy curtain during toileting or changing assistance and confirmed that leaving the door open during ADL care is not an intervention for fall risk management.
Failure to Notify Residents Before Temporary Room Displacement
Penalty
Summary
The facility failed to provide prior notification to residents before temporarily displacing them from their rooms for deep cleaning and floor waxing, affecting two residents reviewed. Resident #27 stated he was moved out of his room without advance notice for 21 hours while the floor was waxed, with his belongings placed in the hallway and him relocated to another room that had no television. He reported staff did not know he had been moved, which made it difficult to receive assistance, and he said several personal items were stolen after being left unattended in the hallway. His record showed diagnoses including unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, and muscle wasting and atrophy, and his MDS showed a BIMS score of 15 indicating intact cognition. Resident #39 was observed in her room while housekeeping deep cleaned multiple rooms in the hallway, with beds, dressers, and other equipment pushed aside and loud machinery audible throughout the area. She stated housekeeping began removing beds and cleaning rooms without giving any advance notice, and during the interview a housekeeping employee opened her door without knocking or announcing and said the room would be cleaned that day. Resident #39 stated she had received no prior notice and would have liked advance notice so she could gather her belongings and decide where to go during the cleaning. Her record showed diagnoses including Crohn's disease, PTSD, major depression, insomnia, and anxiety, and her admission MDS showed a BIMS score of 15 indicating intact cognition. Staff and leadership confirmed residents normally should receive advance notice before room displacement, but that this did not occur.
Failure to Follow Grievance Process for Missing Belongings
Penalty
Summary
The facility failed to follow its grievance process related to a resident’s missing personal belongings. The resident, who had a BIMS score of 15 and was cognitively intact, reported that a mirror, body wash, and a case of water were missing and stated he had already told Social Services and other staff about the issue. He also said this was not the first time belongings had gone missing and that he had been told the facility would reimburse him, but he had not received any further follow-up. Record review showed no grievance had been filed on the resident’s behalf in the grievance log covering June 2025 through June 2026. The SSD confirmed she had spoken with the resident about the missing items and that the NHA had agreed to replace them, but she acknowledged she did not file a grievance and did not follow the grievance procedure. The DON stated she was unaware of the missing belongings and said concerns about missing items should be documented on a grievance form, investigated, and followed up with the resident or representative; she stated the grievance process should have been followed.
Missing Transfer and Discharge Documentation
Penalty
Summary
The facility failed to provide required transfer and discharge documentation and notifications for two residents who were transferred to the hospital. For one resident with diagnoses including hepatic failure, bipolar disorder, COPD, portal hypertension, viral hepatitis, hepatic fibrosis, and hepatomegaly with splenomegaly, the record showed a hospital transfer but did not contain documentation of the bed hold policy, advance directives/DNR, current medications, reason for transfer, date and time of transfer, the receiving location, or notice to the Office of the State Long-Term Care Ombudsman. Staff interviews confirmed there was no nursing documentation, no evaluation, and no way to verify the time the resident went to the hospital. For the second resident, the record showed an unplanned transfer to an acute care hospital after the resident was observed to be lethargic, unresponsive to verbal stimuli, with oxygen saturation of 77 and slow shallow breathing; oxygen was applied and EMS transported the resident to the ER. Although progress notes and a discharge-to-hospital assessment were present, the DON could not locate the AHCA hospital transfer form or the bed hold policy document required upon discharge and stated that if it was not in the record, it was not completed. The facility policy required transfer and discharge documentation, including the bed hold policy, transfer/discharge notification, advance directives/DNR, and current medications/treatments, to accompany the resident or be sent to the receiving hospital.
Failure to Follow PASRR Level II Recommendations
Penalty
Summary
The facility failed to ensure residents received services in the most appropriate setting by not following Level II PASRR recommendations for two residents reviewed. One resident had diagnoses including Parkinsonism, major depressive disorder, generalized anxiety disorder, bipolar disorder, and major depressive disorder, and a PASRR notice dated 12/6/22 indicated signs of a serious mental illness and that a Level II screening was needed. The resident’s clinical record did not show that the facility obtained the Level II evaluation results or followed up with the State PASRR Level II screening entity for the required recommendations. The resident’s active orders included Depakote and Trazodone for mood disorder, insomnia/depression, and major depressive disorder, and a psychiatry note dated 6/3/26 documented the patient was unstable with behavioral outbursts. The second resident was admitted with diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, and generalized anxiety disorder. A PASRR Level II determination summary report stated that if there was a significant change in mental status, an additional Level II review was recommended. The resident’s active orders included Depakote, Lithium Carbonate for agitation/aggression related to schizoaffective disorder, and Trazodone for MDD and anxiety. Staff reported the resident screamed, yelled, was belligerent, and foul mouthed, and the resident was observed yelling in the lobby about money, being confrontational, and difficult to redirect; this behavior was observed more than once daily throughout the survey. The DON stated she thought follow-up Level II screening was related to new diagnoses, not behaviors, and the SSD stated PASRR audits were done but the missing Level II recommendations for the first resident had not been obtained.
PASRR Level I Not Updated for Added Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurate for one resident. The resident was admitted to the facility originally on 4/29/2025 and readmitted on 06/11/2026 with diagnoses including Bipolar Disorder, current episode mixed, moderate; Schizoaffective Disorder, Bipolar Type; Major Depressive Disorder, recurrent, moderate; and other specified anxiety disorders. Review of the resident’s PASRR Level I, dated 5/5/2025, showed schizoaffective disorder as the only qualifying mental health diagnosis. During an interview on 06/11/2026, the Social Service Director and DON stated that PASRR begins at admission and is reviewed and updated as needed, with audits every 3 to 5 months. The SSD stated she reviewed the resident’s PASRR when the resident first admitted, but after serious mental illness diagnoses were added to the medical record, the PASRR was not reassessed or updated to reflect the new diagnoses. Facility policy stated that residents with a mental disorder or intellectual disability must be screened prior to admission and continue to receive appropriate review when a significant change in status occurs.
Failure to Revise Care Plan for Behavioral Expression
Penalty
Summary
The facility failed to ensure Resident #53 had a revised care plan to address behavior concerns after staff observed him writing harmful political phrases on a Styrofoam cup and on a sheet of paper on the wall behind his bed. During the observation, a CNA stated the resident sometimes writes the same phrase on the walls and has had those behaviors. The Social Services Director acknowledged seeing the phrases related to a political figure and stated the resident had been at the facility for a while, kept to himself, and was followed by psychiatry. Resident #53 was admitted with diagnoses including major depressive disorder, recurrent, moderate, other specified persistent mood disorders, and generalized anxiety disorder. His quarterly MDS assessment dated 5/19/26 indicated no behaviors or behavioral symptoms and a BIMS score of 15, showing intact cognition. His care plan addressed mood problems, psychosocial well-being, antidepressant use, and psychotropic medication monitoring, but it did not reflect the observed harmful writing behavior. The psychiatric progress note dated 5/27/26 documented monitoring for thoughts of harming others, but there was no documentation related to the behavior observed on 6/9/26. The MDS Coordinator stated she relied on staff and resident interviews, observed staff during care, and reviewed CNA and nursing documentation, and she confirmed that if a resident started having behaviors, Social Services would initiate a behavior care plan. She said she was not aware of the resident writing harmful messages about a political figure and confirmed he should have a behavior care plan. The NP stated the resident would scream out of nowhere about politics and had been observed using profanity toward the same individual, and she confirmed that writing harmful messages about a political figure would be considered a behavior.
Missed Dialysis Appointments Due to Transportation Failures
Penalty
Summary
The facility failed to ensure one resident with End Stage Renal Disease and dependence on renal dialysis received dialysis services consistent with professional standards of practice. Resident #12 was admitted with diagnoses including ESRD and Type 2 diabetes mellitus with diabetic polyneuropathy, and his care plan identified dialysis on Monday, Wednesday, and Friday with a 6:30 AM chair time and 5:30 AM transportation pickup. Record review showed multiple missed dialysis appointments, including a missed treatment on 5/18/2026, a refusal to go to a scheduled dialysis appointment on 5/20/2026 after missing the prior day because transportation did not arrive on time, and another missed dialysis appointment on 5/22/2026 due to transportation. During interview, the facility transportation driver stated he had never taken Resident #12 to dialysis and had only been asked to take him to a cardiology appointment. He stated he had told the facility he did not mind coming in early to transport the resident to dialysis, but no one followed up with him. The LPN/Unit Manager stated the resident goes to dialysis on Monday, Wednesday, and Friday, but also stated the facility transportation driver was not at the facility that early in the morning. The DON stated the facility was working with the dialysis center to get the resident seen the same day if transportation did not show up, and the facility administration stated they did not have a dialysis policy for this citation.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma informed care for a resident with a documented diagnosis of PTSD. On 6/8/2026, the resident was observed in her room wearing large ear/headphones and stated she was trying to drown out very loud noises from housekeeping activity in the hallway. She reported that housekeeping had come to the hallway without warning and began cleaning rooms with very loud machines, and she stated she did not like loud noises or being given no time to adjust to them. The hallway was observed to have multiple beds, dressers, and equipment, and housekeeping was deep cleaning resident rooms with loud floor cleaning machines and other machines heard throughout the hallway. Record review showed the resident was admitted and later readmitted to the facility, and her diagnosis sheet listed PTSD, major depression, insomnia, anxiety, pulmonary HTN, Crohn's disease, and CHF. The psychiatric assessments dated before and after admission repeatedly identified PTSD and documented trauma history including rape, molestation, and traumatic childhood experiences, with triggers listed as loud noises and unwanted physical touch. Those assessments also directed staff to request and notify the resident when physical care needs were to be provided and to explain what would happen and why. However, the resident's MDS admission assessment checked PTSD as not active, and the current POS and nursing progress notes did not contain specific orders, medications, or documentation related to PTSD, trauma, or triggers. The facility's Resident Matrix report did not identify the resident as having PTSD. Current care plans reviewed on 6/8/2026 focused on functional abilities and behaviors such as refusal of medications, wandering, entering other residents' rooms, and verbal abuse, but did not include a trauma/PTSD focus area. Staff interviews showed the LPN, CNA, ADON, and other direct care staff were not aware the resident had PTSD or that loud noises were a trigger. The DON confirmed the psychiatric assessments showed PTSD and loud-noise triggers, stated the facility had missed this focus area on admission, and confirmed housekeeping had been making loud noises near the resident's room without providing notification so she could adjust to it.
Failure to Document Side Effect Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure side effect monitoring was implemented for a resident receiving psychotropic medications based on pharmacy recommendations. Resident #2 had diagnoses including major depressive disorder, bipolar disorder, generalized anxiety disorder, and mood disorder due to a known physiological condition with mixed features. Physician orders included trazodone, oxcarbazepine, and divalproex sodium, but the chart showed no side effect monitoring orders. The resident’s care plan identified a need to monitor and document side effects and effectiveness for antidepressant and anticonvulsant use, yet the MAR and TAR contained no side effect monitoring documentation in 5/2026 and 6/2026. The consultant pharmacist’s monthly regimen review in 5/2026 included a recommendation to add side effect observations and noted that medications with known psychotropic effects, including seizure medications and other neuroleptics, must be tracked for adverse effects even if not used as psychotropic medications. During interview, the VP of Clinical Operations/RN confirmed the pharmacy recommendations were not implemented for Resident #2 and stated side effect monitoring should have been completed per facility policy. The VP also confirmed there was no documentation that the pharmacy recommendations were addressed by nursing staff or the DON.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5.00%. During observation of 47 medication administration opportunities, surveyors identified 3 medication errors involving 2 residents, resulting in a 6.38% error rate. One RN administered multiple medications to a resident whose blood pressure was 130/72 and blood sugar was 293 mg/dL, including Midodrine 10 mg even though the order required it to be held for systolic blood pressure greater than 110, and Metoprolol Tartrate 50 mg as 1 tablet even though the order was for 1.5 tablets twice daily. When interviewed, the RN stated the Metoprolol order must have just changed and later acknowledged that Midodrine had been given when the blood pressure was out of parameters. A second medication administration observation involved an LPN giving a resident multivitamin with minerals even though the active order was for a multivitamin adult oral tablet. The LPN stated that the doctor would need to be notified that the multivitamin with minerals had been given. The DON stated that nurses were expected to follow medication orders. The facility policy required medications to be administered as prescribed and verified for the right medication, dosage, time, and method of administration.
Improperly Labeled and Undated Medications in Medication Cart
Penalty
Summary
Medications in one medication cart on 2 North were found improperly labeled, dated, and stored during observation with an LPN. Resident #17’s Albuterol AER HFA inhaler was found undated with no open date or expiration date visible. Resident #7’s Fluticasone/Salmeterol inhaler was open and undated, with no open date or expiration date recorded. Resident #34’s Novolog FlexPen was found open but not dated, so the beyond-use date could not be determined. During the observation, the LPN stated medications should be labeled with open and expiration dates and that staff sometimes do not take time to add the dates when first used. The ADON stated nurses are provided resources during orientation about dating opened medications and that she rounds weekly on medication carts to check that in-use insulin and inhaled medications are dated. The DON stated the facility has resources for nurses to determine expiration dates. The facility policy stated that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy before storing and that medications must be stored in a safe, secure, and orderly manner.
Failure to Coordinate Follow-Up Dental Care
Penalty
Summary
The facility failed to coordinate and ensure follow-up dental services for a cognitively intact resident with a history of unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, and muscle wasting and atrophy. The resident had a documented dental history that included a partial tooth extraction with increased pain and a note indicating follow-up monitoring for potential complications. An active order summary showed a dental/oral surgery appointment scheduled for April 30 at 2:00 PM, entered on April 22, 2026, but the electronic medical record contained no documentation that a follow-up dental appointment was ever scheduled. The resident’s POA stated she was never informed whether the tooth extraction appointment occurred and reported that the resident paid monthly for dental services through the facility. Staff V reported transporting the resident to a dental appointment that had been scheduled for the wrong day, and after it was rescheduled, he encountered a language barrier at the dental office and found he was at the wrong location within the building, causing the resident to miss the appointment. The SSD stated the appointment had to be rescheduled, and the unit manager confirmed the resident missed the April dental appointment, did not schedule another follow-up, and did not collaborate with Social Services to coordinate dental care. The DON stated the office later said it could not accept the resident’s insurance, and the facility policy required dental services and oral care to be available and Social Services to assist with dental appointments and transportation arrangements as necessary.
Missed Lunch Tray for Resident Eating in Room
Penalty
Summary
The facility failed to ensure a scheduled lunch meal was provided to a resident who had been eating meals in her room for several weeks because she preferred to avoid larger groups. The resident, who was her own decision maker and had diagnoses including PTSD, major depression, insomnia, and anxiety, stated she had previously eaten in the main dining room but had not done so for nearly a month. On 6/9/2026, meal carts were present in the hallway at 12:04 p.m., but she did not receive a lunch tray in her room. By 1:30 p.m., she was observed with a box of food from an outside restaurant that another resident had given her, and she stated she had not received the facility lunch despite asking an aide and a nurse twice. She confirmed she would have eaten the facility meal if it had been provided. Staff later confirmed the resident did not receive lunch. A CNA and an LPN both acknowledged the meal was not delivered, and the CNA stated he had heard the tray may have been sent to the main dining room and left there, although he was unsure why because the resident had been eating in her room for a while. The Dietary Manager confirmed the tray was not received and believed it may have been sent to the wrong location, but had no documentation showing where it went or evidence that it left the kitchen. The NHA and DON also confirmed the resident did not receive lunch and stated that even if the tray had been delivered to the main dining room, staff should have noticed it remained untouched and ensured it was brought to the resident's room. The facility had no specific policy addressing meal tray delivery.
Nighttime Snack Recipe Not Followed and Milk Held Above Safe Temperature
Penalty
Summary
The facility failed to ensure residents were provided a nourishing nighttime snack by not following the standardized peanut butter and jelly sandwich recipe. During a resident council meeting, residents reported that the bedtime peanut butter and jelly sandwiches were half sandwiches that were thin, had little visible jelly, and contained only a small amount of peanut butter. They stated the jelly used to ooze out previously and that they had voiced concerns to staff and dietary staff. The Dietary Manager confirmed the nighttime snack was peanut butter and jelly sandwiches and stated they were prepared as half sandwiches with one tablespoon of peanut butter and one tablespoon of jelly, which did not match the recipe provided to dietary staff. The recipe required one full sandwich made with 3 1/2 tablespoons of creamy peanut butter, 1 1/4 tablespoons of grape jelly, and 2 slices of bread. The Registered Dietitian stated the sandwiches should be high in calories and protein and confirmed the recipe provided the intended nutritional value. The facility also failed to keep cartons of milk at or below 41 degrees Fahrenheit during lunch service. In the kitchen, cold liquids including poured juices and cartons of milk were observed sitting on the steam table counterspace near hot food items, with no ice chips or ice bath to keep them cold. Staff confirmed the liquids had just been removed from the walk-in refrigerator and had been chilled below 41 degrees Fahrenheit, but they were placed on the counter near the steam table without a method to maintain cold temperature. A random carton of 2% milk was tested and measured 44 degrees Fahrenheit, and staff confirmed it was not within the required temperature range. The facility policy stated potentially hazardous or time/temperature controlled for safety foods must be maintained at or below 41 degrees Fahrenheit.
Inadequate Supervision and Fall Prevention in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision for four residents, leading to multiple unwitnessed falls and injuries. Resident #5, who was at high risk for falls due to severe cognitive impairment and other medical conditions, experienced several falls, including one that resulted in significant facial injuries. Despite being identified as a high fall risk, the resident's care plan interventions, such as increased monitoring and 1:1 supervision, were not consistently implemented. Neuro checks were not conducted as required, and there were lapses in monitoring, as evidenced by gaps in the 30-minute check documentation. Resident #6 also experienced multiple unwitnessed falls, with eight incidents recorded over a few months. The resident, who had severe cognitive impairment and a history of falls, was not adequately supervised, and necessary safety interventions, such as perimeter mattresses and fall mats, were not consistently in place. The facility's documentation was incomplete, with missing neuro checks and post-fall reviews for several incidents. The resident's care plan was not updated to reflect necessary interventions, contributing to the continued risk of falls. Resident #3, with severe cognitive impairment and a history of falls, suffered a fall resulting in a nasal fracture and required hospitalization. The resident's care plan included interventions like perimeter mattresses and 30-minute checks, but these were not effectively implemented. Neuro checks were not documented for a fall on 10/29/2024, and a recommended medication review was not performed. The facility's failure to update the care plan and implement necessary interventions contributed to the resident's fall and subsequent injuries.
Failure to Report Resident's Injury After Unwitnessed Fall
Penalty
Summary
The facility failed to report an injury of unknown origin following an unwitnessed fall for one resident. The resident, who was admitted with severe cognitive impairment and required assistance with personal care, experienced unwitnessed falls on two occasions. On one such occasion, the resident was found sitting on the floor with a laceration and swelling around the eye, and blood was observed on the face and wall. The resident was sent to the emergency room for evaluation and treatment, where a CT scan revealed multiple facial fractures. Despite the severity of the injuries, the incident was not reported as required. During an interview, the Nursing Home Administrator could not recall if the incident had been reported. A review of the facility's Reportable Event Tracking Log confirmed that the fall with major injury had not been documented. This oversight indicates a failure in the facility's protocol for reporting significant incidents involving residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 317 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clearwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clearwater Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Oaks Of Clearwater, The | 0.8 mi | ★★★★★ | 0 | 0 |
| Morton Plant Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Highland Pines Rehabilitation Center | 1 mi | ★★★★★ | 3 | 0 |
| Belleair Health Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.