Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Miracle Hill Nursing & Rehabilitation Center, Inc during CMS and state inspections, most recent first.
Failure to administer ordered antibiotics after hospital return. Two residents returned from the hospital with diagnoses of UTI-related conditions and discharge orders for antibiotics, but no corresponding medication orders were found in the EMR, so the medications did not appear to have been given as prescribed. The DON stated the hospital was supposed to send the discharge med reconciliation and that the primary nurse is responsible for reviewing it and ensuring ordered meds are entered.
A resident with behavioral health needs did not receive prescribed Clonidine patches on multiple occasions due to a medication order discrepancy and communication failures between nursing staff and pharmacy. The order was incorrectly entered as a tablet to be given transdermally, leading to the pharmacy delivering the wrong form. Nursing staff did not promptly escalate the issue, and facility policies for verifying and communicating medication errors were not followed.
A resident with diabetes did not receive prescribed insulin or blood glucose monitoring due to failures in documentation, communication, and staff awareness. Despite abnormal lab results and physician orders present in the chart, nursing staff did not implement diabetes care, and the diagnosis was omitted from the MDS, care plan, and medication records. The resident was hospitalized twice for complications related to unmanaged diabetes.
Three residents requiring assistance with ADLs did not consistently receive necessary bathing and hygiene care, as evidenced by observations of poor grooming, infrequent showers, and incomplete documentation. Staff interviews and record reviews confirmed that scheduled care was not provided or properly documented, and family grievances highlighted ongoing concerns about inadequate personal care.
Surveyors found that two resident rooms were not maintained in a sanitary or homelike condition. One room had a sticky floor and a dried brown substance on the wall that was not fully cleaned, as confirmed by an LPN. Another room had a damaged bedside table with missing paint and a missing drawer knob, as well as walls with deep scratches and exposed plaster, which maintenance staff attributed to the bed's position. These findings reflect a lack of proper upkeep and cleanliness in the resident environment.
A resident admitted with multiple complex medical conditions, including end stage renal disease, diabetes with neuropathy, heart disease, and cirrhosis, did not have these diagnoses properly coded on the admission MDS assessment. The MDS Coordinator acknowledged the error during an interview.
A resident with documented depression and dementia was not referred for a required level 2 PASARR screening, despite the initial assessment indicating suspicion of serious mental illness. Record review showed no evidence of the necessary screening, and staff interviews confirmed the PASARR had not been updated and that facility policy did not address timing or completeness requirements.
A resident with diagnoses of depression, dementia, bipolar disorder, and anxiety disorder did not have an updated PASARR Level 2 screening as recommended. The original PASARR form indicated the need for further review, but no documentation of follow-up was found, and staff interviews confirmed the process was not completed as required.
Surveyors identified that two residents had incomplete care plans, with missing goals and interventions for multiple identified needs, including complex medical conditions and activity participation. Staff interviews confirmed that the care plans had not been fully developed or implemented as required.
A resident at risk for skin breakdown due to decreased mobility, incontinence, and fragile skin developed a pressure ulcer after staff did not consistently assist during incontinence episodes. Although the care plan required weekly skin checks and physician notification of any breakdown, documentation showed a missed skin assessment and lack of follow-up interventions after excoriation was noted. The DON confirmed the assessment was not completed and expected interventions were not implemented.
A resident with contractures in the left upper and lower extremities was not provided with therapy or restorative services for range of motion or splinting since admission, despite care plan goals to prevent complications. Staff interviews and record reviews revealed a lack of therapy screening documentation and no initiation of a restorative program for the resident.
Two residents receiving hemodialysis did not have physician orders documented for dialysis care, services, or monitoring of access sites. Staff interviews confirmed that required orders and assessments were missing from the medical records, and facility policy requiring such documentation was not followed.
Two residents did not receive their ordered medications when an LPN and an RN were unable to locate Zoloft and the correct dose of Coreg, respectively, in the medication cart or Omnicell. Both nurses indicated they would notify the pharmacy and physician, and the DON confirmed that medications are expected to be reordered in advance and should not run out.
Surveyors found that medications were not properly labeled or stored, with several medication cups left in a cart for residents who were not present, and opened medications such as eye drops and nebulizer solutions missing required opened dates. Additionally, a narcotic medication count did not match documentation, as a nurse failed to sign out a dose of Tramadol after administration. These actions were inconsistent with facility policy and accepted professional standards.
Two residents did not receive their prescribed medications because the facility failed to ensure medication availability and administration. An LPN and an RN were unable to provide Zoloft and the correct dose of Coreg, respectively, as the medications were not present on the cart or in the emergency supply. The DON and Administrator confirmed that the QAPI plan only addressed thyroid medications and did not cover other medication availability issues, resulting in these deficiencies.
The facility did not provide documentation showing that two residents received education and were offered influenza immunizations, with records indicating vaccine administration on a future date and no current information available at the time of the survey.
The facility did not provide proper documentation showing that two residents received education and were offered the COVID-19 vaccine. In one case, a vaccine refusal was not signed by the resident or responsible party, and in another, records of education and consent or declination were missing. The DON confirmed the vaccine process but could not provide the required documentation during the survey.
Multiple bedrooms were found to have non-functional call light systems, with some missing call light cords entirely. Observations and staff interviews confirmed that the call system was outdated and not regularly checked by facility staff between outside contractor visits. Facility policy requires the call system to be functional and routinely maintained, but documentation of regular checks was lacking.
The facility did not consistently document the administration of Levothyroxine for two residents, as required by policy. Multiple dates were found where the medication was not signed off on the MAR, and one resident's lab results and provider notes indicated ongoing issues with medication adherence. The DON confirmed that documentation should occur at the time of administration, but this was not done.
Failure to Administer Ordered Antibiotics After Hospital Return
Penalty
Summary
The facility failed to ensure that staff administered antibiotics ordered to treat urinary tract infections for 2 of 3 residents reviewed after their return to the facility following hospitalization. One resident was hospitalized for nausea and vomiting and was diagnosed with a UTI and sepsis syndrome; upon discharge back to the facility, the physician ordered Augmentin 875/125 mg, 1 tablet by mouth twice daily until 10/22/25, but no order for this medication was found in the EMR, so it did not appear that staff administered it as ordered. A second resident was hospitalized and diagnosed with acute cystitis, a type of UTI, and was discharged back to the facility with an order for Ofloxacin 400 mg BID. Review of the EMR also found no order for this medication, so it did not appear that staff administered it. The DON stated that the hospital is supposed to send the discharge medication reconciliation with the resident upon return and reported ongoing issues with receiving paperwork from the hospital; she said the resident's orders must have been missed. She also stated that the primary nurse is responsible for reviewing the reconciliation and ensuring prescribed medications are ordered.
Failure to Administer Prescribed Clonidine Patch Due to Order and Communication Errors
Penalty
Summary
The facility failed to implement the plan of care for one resident regarding medication administration. The resident, who had a diagnosis including bipolar disorder, reported not receiving his prescribed Clonidine patch for several weeks. Review of the medical record confirmed that the Clonidine patch was not administered on two occasions, with documentation indicating the medication was not available and had been reordered. The hospital discharge orders specified a Clonidine patch, but the order entered into the facility's electronic medical record incorrectly listed a tablet to be given transdermally. This discrepancy led to the pharmacy delivering the incorrect form of the medication, and the resident did not receive the intended treatment as ordered. Interviews with staff revealed that nursing was aware of the issue, as a pill was delivered instead of a patch, but the problem was not escalated promptly. The DON acknowledged that the receiving nurse should have verified the order and contacted the pharmacy upon noticing the error. Facility policies required nursing staff to communicate medication order discrepancies to the pharmacy and DON, and to ensure medications are administered as prescribed. However, these procedures were not followed, resulting in the resident missing prescribed doses of the Clonidine patch.
Failure to Provide Diabetes Management and Monitoring
Penalty
Summary
A resident with a history of diabetes mellitus was admitted to the facility and subsequently exhibited significantly elevated blood glucose levels and A1C values on multiple occasions. Despite these abnormal laboratory results, there was no documented intervention, nursing action, or medical orders to address the elevated blood glucose and A1C. The resident was later hospitalized for altered mental status and diagnosed with diabetic ketoacidosis, encephalopathy, and a urinary tract infection. Upon readmission, the resident's diabetes diagnosis was not reflected in the Minimum Data Set (MDS), care plan, or medication administration record, and no blood glucose monitoring or diabetes medications were provided. Interviews with staff revealed a lack of awareness of the resident's diabetic status, and chart checks intended to identify such issues were not consistently performed. Orders for insulin and blood glucose monitoring were present in the physical chart but were not carried out by nursing staff. The nursing admission screening did document new onset diabetes, but this information was not integrated into the resident's ongoing care. The deficiency resulted from failures in communication, documentation, and adherence to physician orders, leading to the resident not receiving necessary diabetes management.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically related to bathing and personal hygiene, for three residents who required such care. One resident was observed to be disheveled, with unbrushed and oily hair, and reported having only two showers since admission, both provided by Occupational Therapy staff. Documentation review showed that scheduled showers were not consistently provided or documented by nursing staff, and the unit manager confirmed that lack of documentation indicated the care was not performed. Another resident was observed with matted and tangled hair, and records showed only four documented baths in a month, with no documentation of bathing or attempts to bathe for the past 30 days. Staff interviews confirmed that refusals should be documented, but there was no evidence of such documentation in the records reviewed. A third resident was noted to have a strong smell of urine and, according to a family member, had not received a shower for several months, only sponge baths, and was left in urine-soaked clothes. Grievance logs indicated repeated family complaints about inadequate bathing care, with documentation showing only a few showers provided and some refusals recorded. The facility's policy required staff to provide appropriate support and assistance with hygiene for residents unable to perform ADLs independently, but observations, interviews, and record reviews demonstrated that this standard was not met for the residents involved.
Failure to Maintain Sanitary and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that the floor in one resident room was sticky and a dried brown substance was present on both the floor and wall in the left corner near the doorway. Although the substance was removed from the floor after initial observation, it remained on the wall during subsequent visits, and the floor continued to be sticky. An LPN responsible for the hallway confirmed the need for cleaning both the floor and the wall, indicating that the room was not maintained in a sanitary or comfortable condition. In another resident room, the bedside table was found to be in poor condition, with missing paint and exposed particle board, and the top drawer lacked a knob. The wall beside the head of the bed was scraped and scratched, exposing multiple paint layers and plaster, while the wall behind the other bed had deep metal-colored scratches. The maintenance staff member acknowledged these issues, noting that the bed's position against the wall caused repeated damage and that the bedside table required replacement. These observations demonstrate a failure to provide a safe, clean, and homelike environment in two occupied rooms.
Failure to Accurately Code Admission Diagnoses on MDS Assessment
Penalty
Summary
The facility failed to accurately identify and code a resident's diagnoses on the Minimum Data Set (MDS) assessment upon admission. Record review showed that a resident was admitted with multiple significant medical conditions, including end stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, atherosclerotic heart disease, chronic ischemic heart disease, hypertension, cardiac pacemaker, cirrhosis of the liver, heart failure, atrial fibrillation, osteoarthritis, and pneumonia. However, these diagnoses were not properly coded on the resident's admission comprehensive MDS assessment. During an interview, the MDS Coordinator confirmed that the admission diagnoses were not coded correctly.
Failure to Complete Required Level 2 PASARR Screening
Penalty
Summary
The facility failed to forward a resident for a level 2 Preadmission Screening and Resident Review (PASARR) as required. Record review for a resident revealed that the PASARR form, dated 7/16/20, indicated both depression and dementia, and the completion section specified that a level 2 screening was needed due to suspicion of serious mental illness. However, there was no documentation in the record that a level 2 screening had been completed. During interviews, a Registered Nurse responsible for PASARR compliance stated that the resident's PASARR had not been updated since 2021 and acknowledged it should have been done. Additionally, the Administrator initially reported there was no specific PASARR policy, and when a policy was later provided, it did not address the timing or completeness of PASARRs.
Failure to Update PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) for a resident with mental health diagnoses. Record review showed that the resident had a PASARR form completed in July 2020, which listed depression and dementia and recommended a Level 2 screening due to suspicion of serious mental illness. However, there was no documentation of a Level 2 screening being completed. Additional diagnoses of bipolar disorder and anxiety disorder were added in subsequent years, but no further PASARR actions were documented. Interviews with staff confirmed that the PASARR process was not followed up as required, and the facility did not have a specific policy addressing the timing of PASARR updates.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, as required. For one resident admitted with multiple complex medical conditions, including end stage renal disease, dependence on dialysis, diabetes with neuropathy, atherosclerotic heart disease, hypertension, cirrhosis, heart failure, atrial fibrillation, osteoarthritis, and pneumonia, the care plan did not include documented goals or interventions for identified focus problems such as risk for falls, complications from anticoagulant use, activity involvement, ADL self-care, and potential complications related to dialysis, diabetes, and cardiovascular disease. Staff confirmed that the care plan remained incomplete since admission, despite the facility's policy allowing 14-21 days to complete care plans after admission assessment. A second resident's care plan was also found incomplete during record review. The care plan for this resident lacked specific instructions and measurable goals regarding activity participation and the resident's level of independence or dependence on staff for meeting emotional, intellectual, physical, and social needs. Staff acknowledged the incompleteness of the care plan and agreed that it required correction. These findings were based on interviews and record reviews conducted by surveyors.
Failure to Consistently Prevent and Address Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to consistently provide services to prevent pressure ulcers for a resident at risk due to decreased mobility, incontinence, and fragile skin. The resident reported developing a pressure ulcer, attributing it to insufficient staff assistance during incontinence episodes. The care plan included weekly skin checks and physician orders for weekly skin assessments with notification of any breakdown. However, documentation showed the most recent skin assessment was completed on 5/24/25, noting redness and excoriation in the groin, buttocks, and perineal area, with no evidence of new orders or progress notes addressing these issues. The DON confirmed that the required skin assessment for 5/31/25 was not completed, despite the treatment administration record being signed off, and that the expected intervention of ordering a barrier cream and further assessment was not carried out.
Failure to Provide Range of Motion and Restorative Services for Resident with Contractures
Penalty
Summary
A resident with contractures in the left upper and lower extremities was observed over several days with her left arm and hand contracted to her chest and abdomen. The resident reported not having received any therapy or restorative services since admission. Record review confirmed that the resident was admitted with contractures and her care plan included a goal to remain free of complications related to contracture and immobility. However, there was no evidence in the medical record that a therapy screening or restorative program had been initiated for her. Interviews with facility staff revealed inconsistencies and lack of documentation regarding therapy screenings. The Director of Therapy stated that screenings were conducted on several dates, but no documentation could be provided. The only documented screening was after the resident experienced falls, and no restorative program had been initiated. The restorative nurse confirmed that the resident had not received any restorative services for splinting or range of motion since admission. This failure to assess and provide appropriate services for range of motion and contracture management led to the deficiency.
Lack of Physician Orders and Monitoring for Dialysis Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents receiving hemodialysis. Record reviews showed that neither resident had physician orders for dialysis care, services, or treatments documented in their medical records. For one resident, although there was an order to receive dialysis on specific days, the order did not specify the dialysis location, transportation times, or instructions regarding holding medications during dialysis. The other resident also lacked physician orders for dialysis services, including monitoring of the fistula site for bruit and thrill, signs of infection, bleeding, pressure bandage, swelling, and details about the dialysis schedule and location. There were no orders to hold medications while at the dialysis center for either resident. Interviews with an LPN and the Director of Nursing confirmed that staff are expected to monitor and assess dialysis access sites before and after treatments and that physician orders should be present in the medical record for such care. Both staff members acknowledged the absence of these required orders for the two residents. A review of facility policy indicated that staff are responsible for verifying physician orders, measuring vital signs, and observing shunt sites before and after dialysis, but these actions were not supported by documented orders in the residents' records.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to provide medications as ordered for two residents during medication administration observations. In one instance, an LPN was unable to administer Zoloft, a medication prescribed for depression, to a resident because it was not available in the medication cart or in the facility's emergency medication supply (Omnicell). The nurse informed the resident that the medication had not arrived from the pharmacy and indicated she would notify the physician and pharmacy. In another instance, an RN was unable to administer the ordered dose of Coreg 12.5 mg, a medication used to treat heart failure, to a different resident because the correct dosage was not available in the medication cart or in sufficient quantity in the Omnicell. The nurse indicated she would notify the pharmacy and physician. The DON stated that it is expected for nurses to reorder medications from the pharmacy seven days before running out and to check the Omnicell if medications are not available, but acknowledged that medications should not run out.
Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed that medications were not stored and labeled according to professional standards and facility policy on two medication carts. On one cart, three medication cups containing medications were found in a drawer, each labeled with numbers, after a nurse prepared them for residents who were not present at the time of administration. The nurse acknowledged that facility policy requires discarding medications if not administered and prohibits pre-pulling medications. Additionally, four bottles of eye drops and a bag of nebulizer medication were found without opened dates, despite the requirement to date medications upon opening due to shortened expiration periods. On another medication cart, two bottles of eye drops were also missing opened dates, and a narcotic card for Tramadol showed a discrepancy between the physical count and the narcotic sign-out sheet, with one tablet unaccounted for and no corresponding documentation in the medication administration record. The nurse responsible admitted to administering the medication but forgetting to sign it out. Facility policies reviewed confirmed the need for dating opened medications and maintaining accurate controlled substance records, including immediate documentation of administration.
Failure to Ensure Medication Availability and Administration Due to Ineffective QAPI
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems related to medication availability and administration. During a survey, it was observed that two residents did not receive their prescribed medications because the medications were not available on the medication cart or in the facility's emergency medication supply (Omnicell). In one instance, a resident did not receive Zoloft, an antidepressant, because it had not arrived from the pharmacy and was not available in the Omnicell. In another case, a resident did not receive the correct dose of Coreg, a medication for heart failure, because the required dosage was not available on the cart or in sufficient quantity in the Omnicell. Interviews with nursing staff and facility leadership revealed that the expectation was for nurses to reorder medications from the pharmacy seven days before running out, and to check the Omnicell or contact the pharmacy if medications were not available. However, these procedures were not followed, resulting in missed medication doses. The Director of Nursing and the Administrator acknowledged that their QAPI plan was limited in scope, focusing only on thyroid medications, and did not address broader issues with medication availability, leading to the deficiencies observed.
Lack of Documentation for Influenza Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that two out of five residents received education and were offered influenza immunizations. Record reviews for these residents showed that the influenza immunization was documented as being administered on a future date, which had not yet occurred. During an interview, the DON confirmed that flu, pneumonia, and COVID vaccines are offered yearly in the fall, but was unable to provide current documentation for the influenza vaccines for these two residents at the time of the survey.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that two of five residents received education and were offered a COVID-19 immunization. For one resident, the record indicated a refusal of the COVID vaccine, but there was no signature from the resident or a responsible party to confirm this decision. For another resident, the medical record lacked both documentation of education and a consent or declination form regarding the COVID immunization. During an interview, the DON stated that COVID vaccines are offered yearly in the fall, but the missing documentation for these residents was not provided before the survey exit.
Failure to Maintain Functional Resident Call System in Multiple Bedrooms
Penalty
Summary
The facility failed to maintain a fully functional resident call system in 4 out of 8 sampled bedrooms, as evidenced by direct observations and staff interviews. During inspections, the call light systems in several rooms were found to be non-functional, with some rooms missing call light cords entirely. These deficiencies were observed in both occupied and unoccupied rooms, and photographic evidence was obtained for at least one instance. The Administrator confirmed that the call system was old and acknowledged the lack of evidence for regular staff checks between the biannual visits by an outside company. Service request documents and invoices indicated ongoing issues with the call system, including its obsolescence and the inability to order new parts for repair. Facility policy requires that the resident call system remain functional at all times and be routinely maintained and tested by the maintenance department. However, the only audit provided by the Administrator was from a previous month, and it showed that some repairs had been made, but there was no documentation of ongoing or recent checks for the rooms found deficient during the survey. The lack of a fully operational call system in multiple rooms demonstrates a failure to adhere to facility policy and ensure residents have a reliable means to call for assistance.
Failure to Document Administration of Thyroid Medications
Penalty
Summary
The facility failed to follow pharmacy documentation procedures for the administration of thyroid medications for two residents. For one resident, review of physician orders and medication administration records (MARs) over a three-month period showed multiple instances where Levothyroxine was not signed off as administered on specific dates. The resident's medical record indicated persistently high thyroid stimulating hormone (TSH) levels, and the resident reported not taking her medication as prescribed. The physician assistant's notes also reflected concerns that the resident had not been receiving her Levothyroxine as ordered while at the facility, leading to dose adjustments. For another resident, the MARs revealed several dates in February and March where Levothyroxine administration was not documented. An interview with the Director of Nursing confirmed that medication administration should be documented at the time of administration, and acknowledged awareness of the documentation lapses. Facility policy requires immediate documentation of all administered medications, but this procedure was not consistently followed for these residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tallahassee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tallahassee Memorial Hospital Extended Care | 2.4 mi | ★★★★★ | 0 | 0 |
| Aviata At The Gardens - Tallahassee | 3.5 mi | ★★★★★ | 10 | 0 |
| Centre Pointe Health And Rehab Center | 3.8 mi | ★★★★★ | 10 | 0 |
| Aviata At Tallahassee | 4.5 mi | ★★★★★ | 26 | 0 |
| Seven Hills Health & Rehabilitation Center | 4.7 mi | ★★★★★ | 7 | 0 |
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