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 North Port Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe and clean environment, with issues such as leaking roofs, black growth, and unlabeled personal items posing risks to residents. The Rosebud unit had stained ceiling tiles and black growth due to condensation and leaks, while the smoking area tent had a large opening. Personal items in a resident room were unlabeled, risking cross-contamination. Maintenance issues were not properly communicated, delaying necessary repairs.
The facility failed to maintain personal hygiene for three residents dependent on staff for daily living activities. A resident with severe cognitive impairment had long, dirty fingernails, while another was frequently found soaked in urine and feces due to inadequate incontinence care and bathing. A third resident had not received a shower since admission, despite requests. Staffing shortages and miscommunication contributed to these deficiencies.
A resident with ESRD did not receive necessary dietary and medication interventions at an LTC facility. Despite physician orders for increased protein intake, the facility failed to document the addition of a daily protein supplement. Additionally, multiple medications were not administered on dialysis days, as confirmed by the resident and staff. The DON was unaware of these issues and stated that medication times should be adjusted for dialysis days.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and unmet care needs for several residents. Residents reported long waits for assistance, particularly at night, and observations confirmed call lights were not answered promptly. Staff interviews revealed consistent short-staffing, with CNAs responsible for 20 to 25 residents, leading to inadequate care and hygiene issues.
A facility failed to ensure residents were free from significant medication errors. An LPN was observed with unlabeled medication cups, leading to delayed administration for two residents. Another resident received her morning medications in the afternoon, and a dialysis patient missed doses on treatment days. The DON was unaware of these issues.
The facility failed to securely store medications for three residents, with an LPN leaving medications unattended and unlabeled. A resident was found with pills left on her breakfast tray and bedside table, while the medication cart contained unlabeled medication cups for two other residents. The LPN confirmed the medications were not stored according to policy.
A resident with severe cognitive impairment was administered multiple psychotropic medications without informing or obtaining consent from their family, who were involved in their care. Despite requests, the facility failed to provide documentation that the family was informed of the medication regimen, risks, and benefits, leading to a deficiency in communication and documentation.
A facility failed to provide a resident with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10123), which is necessary to inform the resident of potential liability for payment and related standard claim appeal rights. Although the resident's services were covered by Medicare Part A, and a Notice of Medicare Non-Coverage form indicated that skilled nursing services would end, there was no documentation that the resident received the required notice. The Admissions Coordinator was unable to provide the signed form for this resident.
A facility failed to provide a Baseline Care Plan (BCP) to a resident's representative within 48 hours of admission, as required. The resident was admitted with multiple diagnoses, including altered mental status. Despite documentation indicating the BCP was reviewed, there was no evidence that the resident's Power of Attorney (POA) received the BCP. Staff interviews revealed confusion about who was responsible for providing the BCP, with some believing it was the MDS office's responsibility. The resident's daughter, the POA, confirmed she was not given necessary information about her mother's care.
A facility failed to document blood sugar results for a diabetic resident as ordered, leading to a deficiency. The resident had orders for blood sugar monitoring and physician notification for specific results, but the MAR only showed check marks without actual results. An electronic summary showed a high blood sugar level without physician notification. Staff confirmed all documentation was electronic, and the DON did not provide requested records.
The facility failed to notify the resident representatives of significant changes for two residents. One resident developed a Stage 3 pressure injury, and another had a facility-acquired pressure wound, but there was no documentation of notifications to the families in the medical records.
Environmental and Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed during the survey. In the Rosebud unit, condensation from an air conditioning vent led to stained ceiling tiles, and black growth was noted on the wall near the nursing station. The Regional Manager of Operations confirmed the roof was leaking and that an inspector was working on obtaining repair estimates. However, the black growth was not previously reported to her. Additionally, the designated smoking area in the courtyard was found to have a large opening in the tent roof, causing residents to get wet when it rained. The Director of Maintenance was unaware of the tent's condition until it was brought to his attention during the survey. In one of the resident rooms, personal items such as urinals and wash basins were found unlabeled and commingled, posing a risk of cross-contamination. The Director of Nursing confirmed that personal items should be labeled and stored separately to prevent such issues. The survey also noted a closet door in disrepair, which had not been reported to the maintenance department. These observations highlight a lack of communication and documentation regarding maintenance needs, leading to delays in addressing environmental concerns and ensuring resident safety.
Failure to Maintain Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for three residents who were dependent on staff for activities of daily living. Resident #20, who had severe cognitive impairment and multiple medical conditions, was observed with long and dirty fingernails, which posed a risk of injury due to her contracted hand. Despite the responsibility for nail care being assigned to both activities staff and CNAs, the resident's nails were not maintained, as confirmed by the Director of Rehabilitation and the Director of Nursing. Resident #33, with a history of dementia and severe cognitive impairment, was found by her daughter to be frequently soaked in urine and feces, indicating a lack of regular incontinence care and bathing. The resident's daughter reported these issues to the administration, but they persisted. A former CNA and an LPN confirmed that staffing shortages led to inadequate care, with CNAs being overwhelmed by the number of residents they had to attend to, resulting in residents being left unchanged and at risk of skin breakdown. Resident #167, who required assistance with personal care due to unsteadiness, had not received a shower since admission, despite multiple requests. The facility's shower schedule was not adhered to, and there was no documentation of any refusal of care by the resident. The Unit Manager and a CNA confirmed that the resident had not received her scheduled showers, and the CNA responsible for showers was often reassigned due to staffing issues, leaving the resident's assigned CNA to complete the task, which was not done.
Deficiency in Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving dialysis, specifically in the areas of dietary management and medication administration. The resident, diagnosed with End Stage Renal Disease (ESRD), hypertension, anemia, and an infrarenal abdominal aortic aneurysm, required hemodialysis three times a week. Despite physician orders and recommendations from a registered dietitian to increase protein intake, the facility did not document the addition of a daily protein supplement to the resident's diet. This lack of documentation was confirmed by the facility's Regional Registered Dietitian and Licensed Practical Nurse (LPN) Staff G, who verified the absence of the required dietary intervention. Additionally, the facility did not adhere to the prescribed medication regimen for the resident. The Medication Administration Record (MAR) showed multiple instances where scheduled doses of medications, including Metoprolol, Nifedipine ER, Renvela, Omeprazole, Aspirin, Nephro-Vite, Zinc, and Vitamin D3, were not documented as administered on dialysis days. The resident reported not receiving breakfast or lunch on dialysis days and confirmed that the facility did not provide Renvela to take with meals at the dialysis center. Registered Nurse (RN) Staff J, assigned to the resident, acknowledged that the resident did not receive morning medications on dialysis days and had not informed the physician about the missed doses. The Director of Nursing (DON) was unaware of the medication administration issues and stated that medication administration times should be adjusted on dialysis days, with the possibility of administering medications at the dialysis center. The DON indicated that any nurse could contact the physician to obtain orders and make necessary changes. The facility's failure to implement dietary and medication interventions as ordered by the physician and recommended by the dietitian resulted in a deficiency in providing the highest practicable physical well-being for the resident.
Inadequate Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in delayed responses to call lights and inadequate care. Several residents reported waiting extended periods for assistance, particularly during the night shift. For instance, one resident mentioned waiting an hour for help to return to bed after using the bathroom, while another resident had to wait 15 minutes, resulting in an accident. Observations confirmed that call lights were not answered promptly, with one emergency call light going unanswered for nearly eight minutes. The report highlights specific instances where residents' needs were not met due to staffing shortages. One resident was found with long and dirty fingernails, which were not attended to despite being observed by multiple staff members. Another resident was found in the hallway soaked in urine and feces, with a history of not receiving regular showers, leading to a bacterial infection. The facility's records showed that this resident received only three showers over a period of nearly a month. Interviews with staff revealed that the facility was consistently short-staffed, particularly at night, with CNAs responsible for 20 to 25 residents each. Staff expressed concerns about the workload and the impact on resident care, with reports of residents being left unchanged and soaked in urine. Despite these concerns being raised with the administration, staff were reportedly told to disregard them, indicating a systemic issue with staffing and care provision.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the mishandling of medication administration for four residents. On one occasion, an LPN was observed with several pills in unlabeled cups on a medication cart, which were intended for two residents but were not administered at the scheduled time. The LPN admitted to not administering the medications within the required timeframe, which included critical medications for conditions such as high blood pressure and atrial fibrillation. Another incident involved a resident who was upset because she was offered her morning medications in the afternoon, contrary to her usual routine. The LPN left a cup of medications unsecured at the resident's bedside, which included medications for pain, hypertension, and seizures. The administration of these medications was significantly delayed, as they were scheduled for the morning but documented as given over five hours later. Additionally, a resident undergoing dialysis did not receive his morning medications on dialysis days, as confirmed by both the resident and the RN assigned to him. The medications were not administered before the resident left for dialysis, and the physician was not notified of the missed doses. The Director of Nursing was unaware of this issue and acknowledged that the medication administration times should have been adjusted for dialysis days.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store medications securely and in accordance with its policies, affecting three residents. During an observation, Resident #67 was found with Nystatin powder and multiple pills left unattended on her breakfast tray. The resident mentioned that the nurse left them there for her to take with breakfast. Later, a medication cup with five pills was observed unsecured on her bedside table, and the resident expressed confusion, believing the nurse was trying to trick her into taking medications she had already taken. LPN Staff S confirmed that he left the medications unattended at the resident's bedside. Further observations revealed that the medication cart on the rose bud unit contained several pills in two unlabeled plastic medication cups placed on an alcohol wipe packet. One wipe was labeled with Resident #4's name and the other with Resident #63's name. LPN Staff S identified the medications in the cups as belonging to these residents and acknowledged that they were not labeled or stored according to the facility's policy. He admitted that the medications should have been discarded when not administered on time.
Failure to Inform Resident's Family of Psychotropic Medication Use
Penalty
Summary
The facility failed to uphold the rights of a resident to be informed and involved in their medication management, specifically concerning the use of psychotropic medications. The resident, who was admitted with a history of Bipolar Disorder, Anxiety, Major Depressive Disorder, Unspecified Mood Disorder, Dementia with behavioral disturbance, and Confusional Arousal, was noted to have severely impaired cognition. Despite this, the facility did not ensure that the resident's representatives were informed about the administration of multiple psychotropic medications, including Buspirone, Depakote, Haloperidol, Risperdal, Seroquel, and Alprazolam, nor were they informed of the associated risks and benefits. Interviews with the resident's daughter-in-law revealed that neither she nor her husband were made aware of the resident's medication regimen or the behaviors that prompted the use of these medications, including multiple Haldol injections. The facility's Director of Nursing confirmed that the resident was not capable of making informed decisions and that the family was involved in her care. However, despite multiple requests, the facility failed to provide documentation that the family was informed or consented to the use of these medications, highlighting a deficiency in communication and documentation regarding the resident's care plan.
Failure to Provide Required Non-Coverage Notice
Penalty
Summary
The facility failed to provide a resident with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10123), which is necessary to inform the resident of potential liability for payment and related standard claim appeal rights. The resident's services were covered by Medicare Part A, and a Notice of Medicare Non-Coverage form indicated that skilled nursing services would end on a specific date. However, there was no documentation that the resident received the required notice. An interview with the Admissions Coordinator revealed that the facility typically obtains a signed form to denote that the conversation occurred with the resident or responsible party, but they were unable to provide the signed form for this resident.
Failure to Provide Baseline Care Plan to Resident's Representative
Penalty
Summary
The facility failed to ensure that a Baseline Care Plan (BCP) was provided to a resident and their representative within 48 hours of admission, as required by federal regulations. The resident, identified as Resident #94, was admitted with diagnoses including altered mental status, hypertension, muscle weakness, an open wound of the lower leg, and paroxysmal tachycardia. Although the Admission Nursing Evaluation indicated that the BCP was reviewed by the Interdisciplinary Team and a copy was offered to the resident or their representative, there was no documentation confirming that the resident's Power of Attorney (POA) received the BCP. Interviews with staff revealed confusion about the responsibility for providing the BCP to the resident or their family, with some staff believing it was the responsibility of the MDS office rather than the admitting nurse. The resident's daughter, who is the POA, reported that she was not informed or provided with her mother's admitting diagnoses, medication list, or other pertinent information. The Director of Nursing confirmed the lack of documentation showing that the BCP was provided to the resident's POA within the required timeframe. This deficiency highlights a breakdown in communication and documentation processes within the facility, leading to the failure to meet regulatory requirements for providing essential care information to the resident's representative.
Failure to Document Blood Sugar Results for Diabetic Resident
Penalty
Summary
The facility failed to document blood sugar results as ordered for a resident with diabetes, leading to a deficiency. The resident, who was readmitted with diagnoses including stage 3 chronic kidney disease and type 2 diabetes, had physician orders to inject Lantus insulin and to obtain finger-stick blood sugar twice daily. The orders specified that the physician should be notified for blood sugar results less than 60 or greater than 300 mg/dl. However, the Medication Administration Record (MAR) for several months showed only check marks and initials indicating that the blood sugar was obtained, without documenting the actual results. The electronic blood sugar summary revealed several recorded blood sugar levels, including a result of 333 mg/dl, which exceeded the threshold for physician notification. There was no documentation that the physician was notified of this result. Interviews with nursing staff confirmed that all documentation was entered into the computer system, with no paper records maintained unless the system was down. Despite multiple requests, the Director of Nursing did not provide the requested documentation of blood sugar results for the specified period.
Failure to Notify Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify the resident representative of significant changes for two residents reviewed for significant changes. Resident #4 was admitted for rehab after a urinary tract infection and cerebrovascular accident and was not cognitively intact. A skin check revealed a Stage 3 pressure injury, but there was no documentation of a change in condition or notifications to the family in the medical record. Although the resident's daughter was informed during a visit, the facility did not follow its policy to notify the resident's representative immediately upon discovering the wound. Resident #6, who had a history of dementia and chronic kidney disease, was readmitted to the facility and identified as having a facility-acquired pressure wound. An initial wound care consult was conducted, but there was no documentation of a change in condition or notifications to the family in the medical record. The Director of Nursing and the Administrator acknowledged the oversight and mentioned a Performance Improvement Plan for notifying the physician and family when wounds are identified, but no evidence or documentation was provided for the notifications for either resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Port
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Harbor Healthcare | 7 mi | ★★★★★ | 0 | 0 |
| Port Charlotte Rehabilitation Center | 7.6 mi | ★★★★★ | 3 | 2 |
| Douglas Jacobson State Veterans Nursing Home | 9 mi | ★★★★★ | 0 | 0 |
| Aviata At Englewood | 9.1 mi | ★★★★★ | 4 | 0 |
| Sunset Lake Healthcare And Rehabilitation Center | 9.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North Port Rehabilitation And Nursing Center.
100% money-back within 48 hours.
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.