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 Indigo Manor during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions and proper food handling practices in the kitchen cooking area, with persistent food residue on equipment and cookware, grease buildup, and debris and grime on the floors observed during two separate tours the same day. Dietary staff and the CDM reported that cooks are responsible for cleaning the cook area daily, dietary aides clean other designated areas, and that a written cleaning schedule and Food Safety/Sanitation policy are in place, but the ongoing accumulation of grease and soil showed that these responsibilities and policies were not effectively carried out.
A resident with severe cognitive impairment, multiple chronic conditions including COPD, type II DM, CKD stage 2, and dementia, and who was dependent on staff for ADLs, was observed with jagged fingernails on both hands extending about 1/2 inch beyond the nail bed. The resident stated he did not like his nails so long. Staff, including a CNA and an LPN, acknowledged the nails were too long and reported that nail care is typically done on shower days. The ADON described a process for CNAs to document shower assistance and indicate when fingernails need attention, but the resident’s shower sheets lacked any notation that fingernail care was needed. This occurred despite a care plan and ADL policy requiring assistance with hygiene and grooming to keep the resident clean and well-groomed.
A resident with multiple chronic conditions, including DMII, COPD, CHF, and major depressive disorder, was found with two unused disposable razors left unattended on the bedside table. The resident reported that a CNA had brought the razors in and left before providing shaving assistance. An RN later removed the razors, stating that residents are not allowed to keep disposable razors in their rooms and that CNAs should remove them after use. A CNA assigned to the resident reported she had provided care earlier and had not seen razors in the room. The DON confirmed that razors are not permitted in resident rooms and referenced facility policy requiring prevention and reporting of injuries related to sharp instruments.
The facility failed to maintain proper sanitation and food handling practices, as observed through inconsistent dish machine temperatures and chemical sanitization levels. Staff interviews revealed a lack of training and knowledge regarding proper procedures, and the mixer was found with food buildup. These deficiencies posed a potential risk of foodborne illness to residents.
A resident dependent on staff for ADLs had toenails extending half an inch beyond the nail bed, posing a snagging risk. Despite staff awareness of the resident's needs, toenail care was not provided, and no request for podiatry was made. The resident's medical record showed multiple diagnoses, including diabetes, complicating toenail care. The facility's ADL policy was not followed, resulting in this deficiency.
A resident with severe cognitive impairment was found with smoking materials, including a lighter, despite the facility's policy prohibiting residents from keeping such items. The resident, who has a history of dementia and behavioral disturbances, was noncompliant with the smoking policy, which required staff to manage smoking materials and supervise smoking breaks. Interviews with staff revealed that the resident frequently obtained lighters from visitors, and despite being counseled on the safety risks, continued to keep them.
A resident received oxygen at an incorrect flow rate, contrary to the physician's order of 2 L/min. The discrepancy was confirmed by an LPN, and the resident's medical record lacked a prior oxygen order. The facility's policy required correct oxygen settings to be communicated and verified, but the resident's care plan did not address oxygen therapy, indicating a lapse in adherence to professional standards.
The facility's medication error rate exceeded 5% due to two incidents where staff nearly administered incorrect medications to residents. An RN almost gave Oxycodone-Acetaminophen to the wrong resident, and an LPN prepared Docusate Sodium for a resident without an order for it. Both errors were caught before administration, highlighting lapses in the verification process against the MAR.
Failure to Maintain Sanitary Kitchen Conditions and Follow Food Service Cleaning Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions and proper food handling practices in the kitchen cooking area. During a kitchen tour on 2/17/26 at 10:15 a.m., they observed food residue on equipment and cookware, grease buildup, accumulated debris, and grime on the kitchen floor in and around the cooking area, with photographic evidence obtained. A follow-up tour at 3:27 p.m. the same day revealed the same unsanitary conditions, indicating that the issues had not been addressed during that time frame. These conditions were inconsistent with the FDA Food Code 2022 requirements that equipment food-contact surfaces and utensils be clean to sight and touch, free of encrusted grease deposits and soil accumulations, and that nonfood-contact surfaces be free of dust, dirt, food residue, and other debris. Interviews with dietary staff and review of facility policies further demonstrated a breakdown in implementation of the facility’s Food Safety/Sanitation policy. A dietary aide stated that cooks are responsible for cleaning the kitchen and food service equipment daily or after each use, and that dietary aides clean the microwave and ice machine in nourishment rooms. The Certified Dietary Manager (CDM) reported that cooks are responsible for cleaning the cook area, that she is responsible for ensuring daily cleaning is completed, and that the last deep cleaning of the kitchen occurred in January 2025, with a goal to schedule another by the end of the current month. Another dietary aide described daily cleaning routines for tray lines, carts, belts, and floors, while a cook reported that the scheduled cook is responsible for cleaning the cook area but that not all staff participate as expected, prompting him to inform the CDM when this occurs. Despite these stated responsibilities and the written comprehensive cleaning schedule, the observed persistent grease buildup, food residue, and floor grime in the cooking area showed that the facility did not follow its own sanitation policy or professional standards for food service cleanliness.
Failure to Provide Required Fingernail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide fingernail care as part of activities of daily living (ADLs) for one resident who was dependent on staff for personal hygiene. Surveyors observed the resident seated in a wheelchair near the south unit nurse’s station with several fingernails on both hands jagged and extending approximately 1/2 inch beyond the nail bed, with photographic evidence obtained. When asked, the resident stated he did not like his nails so long but could not remember if he had asked staff to trim them. Record review showed the resident had COPD, type II diabetes mellitus without complications, pseudobulbar affect, stage 2 chronic kidney disease, and dementia, with a BIMS score of 7/15 indicating severe cognitive impairment. The MDS and care plan documented that the resident required extensive to dependent assistance with ADLs and was to be kept clean and well-groomed, with staff assisting with hygiene, including bathing and grooming. Staff interviews confirmed that the resident’s fingernails were excessively long and should have been trimmed. A CNA stated that fingernails are usually trimmed on shower days when nails are softer, and an LPN who administered medications to the resident that morning acknowledged the nails were much too long but had not noticed them earlier. A unit manager and the ADON explained that CNAs and nurses are permitted to trim or file fingernails, and that for diabetic residents a nurse must trim the nails. The ADON described a process in which CNAs document shower assistance on shower sheets and indicate when fingernails need attention by circling a body diagram; however, a review of the resident’s shower sheets showed no documentation that fingernail care was needed. The facility’s ADL policy stated that residents unable to carry out ADLs independently are to receive services necessary to maintain grooming and personal hygiene, including hygiene such as bathing, dressing, grooming, and oral care, but this was not carried out for this resident’s fingernail care.
Unattended Disposable Razors Left in Resident Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when disposable razors were left unattended on a resident's bedside table. During observation on 02/17/26 at 11:13 AM, two unused disposable razors were seen on the bedside table of Resident #7. The resident stated that a CNA had brought the razors into his room and then abruptly left before providing shaving assistance, and he could not recall the CNA's name or whether this occurred during the day or night shift. Resident #7's medical record showed he was admitted with multiple diagnoses, including muscle wasting and atrophy, muscle weakness, type II diabetes, COPD, peripheral vascular disease, chronic systolic (congestive) heart failure, and major depressive disorder. He was documented as alert and oriented to person, place, and time, able to communicate verbally with clear speech, and able to understand and be understood by others. Later that day at 12:33 PM, RN G was observed removing the two disposable razors from the resident's room and stated that the razors did not appear to be facility-issued and might have been brought in by a family member. She explained that residents are not permitted to keep disposable razors in their rooms and that CNAs are expected to remove razors after providing shaving assistance. At 12:53 PM, CNA H, who was assigned to the resident and familiar with his care needs, reported that she had provided care in the resident's room that morning and did not notice any disposable razors on the bedside table. She stated that residents are not permitted to have disposable razors unattended in their rooms and that she would have removed and reported them if she had seen them. The DON confirmed during an interview at 5:20 PM that razors are not permitted in resident rooms and referenced facility expectations and a policy titled "Needlesticks and Cuts" requiring personnel to follow procedures to prevent injuries from sharp instruments and to report such incidents.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a kitchen tour and through staff interviews. The dish machine temperature logs for January, February, and March 2025 consistently showed wash temperatures of 140 degrees Fahrenheit and rinse temperatures of 145 degrees Fahrenheit, which were not in compliance with the facility's policy. Additionally, the chemical sanitization levels for the 3-compartment sink were recorded at 190 ppm, which did not align with the required levels. Staff interviews revealed inconsistencies in training and knowledge regarding the correct procedures for ware washing and chemical sanitization. During the kitchen tour, it was observed that the mixer had brownish-colored food buildup on the back handle and under the safety guard, indicating a lack of proper cleaning. Staff interviews further highlighted a lack of clarity and training among dietary aides regarding the use and cleaning of the dish machine and 3-compartment sink. Some staff members were unsure of the correct temperature and ppm levels required for proper sanitation, and there was confusion about the frequency and responsibility for logging these details. The facility's policies and procedures for cleaning equipment and using the dish machine and 3-compartment sink were not being followed consistently. The Certified Dietary Manager confirmed the discrepancies in staff knowledge and the lack of a tracking method to ensure cleaning duties were completed. The failure to maintain proper sanitation practices in the kitchen posed a potential risk of foodborne illness to all residents consuming food from the facility's kitchen.
Failure to Provide Adequate Toenail Care
Penalty
Summary
The facility failed to provide adequate toenail care for a resident who was dependent on staff for activities of daily living (ADLs). Observations on two consecutive days revealed that the resident's toenails extended approximately one half inch beyond the nail bed and were jagged, posing a potential risk for snagging and scratching. Despite attempts to interview the resident, he did not respond, and there was no documentation of toenail care being provided. Interviews with facility staff, including a CNA and an LPN, revealed inconsistencies in the process of identifying and addressing the resident's toenail care needs. The CNA, who was familiar with the resident's care needs, admitted to not checking the resident's toenails during recent care activities. The LPN stated that facility staff were not permitted to trim toenails and that she would refer residents to social services for podiatry appointments if long toenails were observed. However, no such request was made for the resident in question. The resident's medical record indicated a range of diagnoses, including diabetes mellitus and diabetic polyneuropathy, which could complicate toenail care. The care plan included interventions for nail care as needed, but there was no evidence of recent toenail care being provided. The facility's policy on ADLs emphasized the provision of necessary services to maintain personal hygiene, yet the resident's toenail care needs were overlooked, leading to the deficiency.
Resident Found with Smoking Materials Despite Facility Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for Resident #7, who was found with smoking materials on his person. On multiple occasions, Resident #7 was observed with a cigarette lighter, despite the facility's policy prohibiting residents from keeping lighters due to safety concerns. The resident, who has a history of dementia and other cognitive impairments, was noncompliant with the smoking policy, which required staff to manage smoking materials and supervise smoking breaks. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), revealed that Resident #7 frequently obtained lighters from visitors and kept them, despite being informed of the safety risks. The CNA, responsible for supervising smoking breaks, stated that residents were not allowed to use lighters and that she had not observed Resident #7 with a lighter. However, the ADON confirmed that the resident had been repeatedly counseled about the dangers of keeping lighters and the facility's smoking policy. Resident #7's medical records indicated severe cognitive impairment and a history of behavioral disturbances, which may have contributed to his noncompliance with the smoking policy. The care plan for Resident #7 included interventions to document non-compliance and educate the resident on the risks of unsafe smoking behaviors. Despite these measures, the facility's failure to prevent Resident #7 from accessing and keeping smoking materials on his person resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, as evidenced by the incorrect administration of oxygen therapy. The resident was observed receiving oxygen at a flow rate of 3.25-3.50 L/min, despite the physician's order specifying a flow rate of 2 L/min. This discrepancy was confirmed by an LPN who noted that the oxygen flow rate was set at 4 L/min during a subsequent check. The facility's policy required nursing staff to ensure the correct oxygen flow rate by reviewing the resident's chart and communicating settings through shift reports. However, the resident's medical record did not contain an oxygen order prior to the observation of the incorrect flow rate, and there was no care plan for oxygen therapy in place. The resident involved had a complex medical history, including hypertensive heart disease, major depressive disorder, insomnia, anxiety disorder, dementia, and was receiving palliative care. The resident was not identified as requiring oxygen in the Quarterly MDS assessment, and the active care plan did not address oxygen therapy. The facility's policy on medication administration emphasized adherence to physician orders and professional standards, yet the failure to administer oxygen at the correct flow rate indicates a lapse in following these guidelines. The deficiency was identified through observation, interviews, and a review of the resident's medical records and facility policies.
Medication Error Rate Exceeds 5% Due to Verification Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate due to two medication errors involving two residents. The first incident occurred when a Registered Nurse (RN) prepared Oxycodone-Acetaminophen for a resident but almost administered it to the wrong resident. The RN was stopped and asked to verify the medication details, which led to the acknowledgment of the near error. This incident highlights a lapse in the verification process of ensuring the correct patient receives the correct medication. The second incident involved a Licensed Practical Nurse (LPN) who prepared Docusate Sodium for a resident who did not have an order for it. The LPN was asked to recheck the medication against the resident's Medication Administration Record (MAR) and realized the error, as the resident was supposed to receive Senna instead. This error underscores the importance of cross-referencing medications with the MAR to prevent unauthorized medication administration. Both incidents reflect a failure to adhere to the facility's medication administration policy, which requires verification of resident identity and medication details.
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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 Daytona Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emory L Bennett Memorial Veterans Nursing Home | 0.9 mi | ★★★★★ | 0 | 0 |
| Gardens Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 15 | 0 |
| Solaris Healthcare Daytona | 1.6 mi | ★★★★★ | 0 | 0 |
| Coastal Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Daytona Beach Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.