Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Ocala Health And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow EBP and IV access infection control practices for multiple residents with central lines, wounds, catheters, and other devices. CNAs provided high-contact care such as incontinence care, transfers, and bed making while wearing gloves but no gowns, and an LPN administering IV meds to residents with PICC or midline access did not properly scrub and dry the needleless connector before use. Staff acknowledged the PPE and cleansing lapses, and the DON confirmed gowns and gloves were required for these care activities.
Two residents had inaccurate assessment coding. One resident’s PASRR omitted bipolar disorder despite admission records and later MDS coding showing psychiatric diagnoses, while staff noted the diagnosis had been questioned and a new PASRR was completed. Another resident’s quarterly MDS failed to code insomnia and mood disorder even though the chart, physician orders, progress notes, and psychiatry documentation supported those diagnoses.
A resident with mood disorder, depression, anxiety, and dementia with agitation was admitted without a PASRR Level II evaluation despite a prior PASRR indicating a Level II was required for suspected SMI. The record noted a history of soft restraints in the hospital to prevent self-harm, and staff interviews confirmed the Level II had not been completed because the resident came from another facility and it was assumed to already be done.
PASRR screening was not accurately completed for a resident admitted with depression. The PASRR did not identify the resident's depression under mental illness, even though the record showed a depression diagnosis, a mirtazapine order for depression, and a later psych note documenting depression and anxiety. The DON and Social Services Director both acknowledged the PASRR should have been updated to reflect the depressive diagnosis.
Missed wound dressing changes for two residents were observed and documented. One resident had a chin dressing left in place beyond the ordered daily change schedule, and another had bilateral lower-leg dressings still dated from earlier despite orders for QOD changes and PRN care. An LPN confirmed one dressing should have been changed, another LPN said she would not know wound care was due if the system did not show it, and the DON stated staff should complete dressing changes as ordered and as needed.
An LPN failed to follow PICC and midline catheter procedures for two residents receiving IV therapy. One resident with a PICC had a transparent dressing with lifting edges exposing the insertion site, and the LPN did not clean the connector long enough, did not allow it to dry, and did not verify blood return before giving NS and heparin. For another resident with a midline catheter receiving meropenem, the LPN again scrubbed the connector briefly, did not let it dry, and did not verify patency before administering IV meds. The DON stated staff should follow central line policy.
A facility failed to keep nurse staffing information posted and updated daily. Surveyors observed the staffing sheet posted with an outdated date, and the Administrator later acknowledged the posting had not been updated and was in the process of being updated.
Two residents received Midodrine outside ordered BP parameters. One resident with hypotension, HTN, and severe cognitive impairment had multiple doses given when SBP was above the hold limit and some doses held when SBP was below the limit; another resident received Midodrine several times when SBP exceeded the ordered hold threshold. Staff interviews showed nurses relied on the MAR and did not consistently follow the physician parameters, while the DON stated staff were expected to check BP and follow the order.
A facility failed to keep accurate MARs and pain records for three residents. One resident had inconsistent pain assessments and late-charted oxycodone administrations, with staff stating pain was sometimes assessed after medication was given or not completed at the end of shift. Two residents receiving midodrine had documentation that did not match ordered hold parameters, including entries showing the medication given when systolic BP was above the limit or when BP was not documented, and staff acknowledged possible charting errors and incomplete medication documentation.
A facility failed to accurately complete a resident's discharge assessment. A resident was discharged to a skilled nursing facility (SNF) out of state, but the Minimum Data Set (MDS) incorrectly recorded the discharge status as to a short-term general hospital. This error was confirmed by the LTC MDS Coordinator and another MDS Coordinator during interviews.
A resident initially admitted for respite care with diagnoses including dementia and mood disorder transitioned to long-term care without a completed PASRR. The facility failed to update the PASRR, as confirmed by staff interviews, despite policy requirements for Level I Determinations to be completed at admission.
A resident with hypotension received Midodrine HCL 5 mg despite having systolic blood pressure readings above the physician-ordered threshold. The facility's staff did not adhere to the specified parameters, as confirmed by interviews with the DON and an APRN. The facility's policy requires verification of medication parameters before administration, which was not followed.
A resident with a restriction against using straws due to choking risk was observed with drinks containing straws on their lunch tray. Despite clear orders and meal ticket instructions, staff failed to adhere to this precautionary measure. Interviews revealed a lack of awareness and adherence to the dietary restrictions, highlighting a deficiency in the facility's protocol implementation.
The facility failed to store food safely in three nourishment rooms, lacking thermometers in freezer compartments and having ice buildup. An undated pizza serving was found, and the Certified Dietary Manager confirmed these issues, acknowledging the need for defrosting and proper dating of food items.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and documentation. One resident's pain levels were inaccurately recorded, despite receiving pain medication, while another resident experienced confusion in insulin administration due to conflicting orders. The facility's documentation policy was not adhered to, resulting in discrepancies in care.
The facility failed to ensure proper use of PPE and adherence to infection control standards. A CNA did not wear required eye protection while caring for COVID-19 positive residents. An LPN used a blood pressure cuff on multiple residents without sanitizing it, and another LPN placed tissues on an unsanitized table. Additionally, a medication syringe was not cleaned after use. These actions were against the facility's policies, as confirmed by the DON.
Failure to Use PPE and Follow IV Connector Cleansing Practices
Penalty
Summary
The facility failed to ensure staff used appropriate PPE while providing care to residents on enhanced barrier precautions. Resident #11 had diagnoses including end stage renal disease, diabetes with chronic kidney disease, dependence on renal dialysis, atherosclerotic heart disease, and hemiplegia following cerebral infarction. During incontinence care and dressing assistance, two CNAs were observed wearing gloves but not gowns, even though the resident had physician orders for enhanced barrier precautions due to a right chest central line for dialysis. Both CNAs later stated they should have worn gowns. Resident #8 had diagnoses including end stage renal disease, diabetic neuropathy, hemiplegia and hemiparesis, and dependence on renal dialysis, with an order for enhanced barrier precautions due to a right chest perm-a-cath for dialysis every shift. A CNA was observed performing hand hygiene and donning gloves before providing incontinence care, but no gown was worn. The CNA stated the resident was on enhanced barrier precautions because of the dialysis catheter and that a gown should have been worn. Resident #175 had diagnoses including osteomyelitis of the lumbar vertebrae, diabetes, hypertensive heart disease with heart failure, and hypertension, with orders for enhanced barrier precautions due to a PICC line and IV antibiotic therapy. A CNA provided incontinence care without a gown, and an LPN administering IV medication wore gloves but no gown. The LPN scrubbed the needleless connector with alcohol for less than 1 second, did not allow it to dry, and immediately administered normal saline followed by heparin. The LPN stated a gown should have been used and that the connector should have been cleaned longer. The policy required vigorous cleansing of needleless connectors with alcohol and allowing them to air dry. Resident #18 had diagnoses including streptococcal arthritis of the right knee, multiple myeloma, status gastrostomy, and presence of urogenital implants, with enhanced barrier precautions ordered related to a Foley catheter and PEG. A CNA was observed providing incontinence care while wearing gloves but no gown and later stated a gown should have been worn. Resident #36 had vascular dementia and a stage 2 right buttock wound with enhanced barrier precautions ordered due to the wound; a CNA provided incontinence care with gloves but no gown and stated a gown should have been worn. Resident #16 had a stage 2 sacral wound and enhanced barrier precautions ordered; staff used a Hoyer lift to transfer the resident and made the bed while wearing gloves and a surgical mask but no gown. One CNA stated they did not know they had to wear PPE when floating, and the DON stated staff should wear a gown and gloves when transferring the resident in a Hoyer lift or making the bed. Resident #27 had diagnoses including acute pyelonephritis, diabetes with neuropathy, obstructive and reflux uropathy, sepsis, UTI, and ESBL resistance, with orders for IV meropenem and flushing the midline catheter pre- and post-antibiotic therapy. During medication administration, an LPN donned a gown but scrubbed the needleless connector for 1 second, did not allow it to dry, and immediately attached the IV antibiotic. The LPN stated the connector should have been cleaned longer, and the DON stated staff should wear PPE when residents are on enhanced barrier precautions and follow infection control practices. The facility policy stated enhanced barrier precautions require gowns and gloves during high-contact care activities and during device care or use of central lines, urinary catheters, feeding tubes, tracheostomies, and wound care.
Inaccurate MDS and PASRR Diagnosis Coding
Penalty
Summary
The facility failed to ensure that resident assessment information was accurate for two residents reviewed for PASRR and MDS coding. For one resident, the PASRR dated 8/16/2024 listed mood disorder and PTSD as the only diagnoses and did not check bipolar disorder, even though the admission record documented bipolar disorder, PTSD, and unspecified mood disorder. The resident’s later quarterly MDS dated 8/27/2025 coded bipolar disorder and PTSD in Active Diagnoses, but the record also showed no antipsychotic medication or indication documented in the High-Risk Drug Classes section. During interview, the DON stated the resident had another PASRR that included bipolar disorder, but the wife said he never had that diagnosis, so a new PASRR was completed without bipolar disorder. A facility MSW letter stated she found the PASRR had an improper diagnosis, confirmed with the resident, wife, and VA social worker that he had never been diagnosed with bipolar disorder, and then completed a new PASRR listing PTSD and mood disorder. Staff also stated the quarterly MDS did not require PASRR review and that they were not aware the resident did not have bipolar disorder. For the second resident, the admission record documented mood disorder due to known physiological condition with mixed feature and insomnia, and physician and progress notes showed ongoing treatment and documentation for insomnia and mood disorder, including melatonin use and psychiatric follow-up noting depression, anxiety, dementia, mood disorder, and insomnia. However, the quarterly MDS did not code insomnia or mood disorder in Section I Active Diagnoses. The MDS LPN stated the assessment should have included insomnia as an active diagnosis, and the Regional MDS Case Manager stated mood disorder should have been coded in Section I.
Failure to Complete PASRR Level II for Resident with Behavioral Health Diagnoses
Penalty
Summary
The facility failed to submit a PASRR Level II evaluation for one resident with behavioral health diagnoses. The resident was admitted on 5/12/2025 with diagnoses including mood disorder due to known physiological condition with mixed feature, depression, anxiety, and adjustment disorder. The resident’s prior PASRR dated 1/30/2024 stated that the individual may not be admitted to a nursing facility and that a Level II PASRR evaluation was required because of a diagnosis or suspicion of serious mental illness. The resident’s 5/13/2025 progress note documented a history of requiring soft restraints in the hospital to avoid self-harm and noted ongoing treatment for mood disorder, depression, and dementia with agitation, including trazodone, Remeron, donepezil, and monitoring of behaviors. Review of the record did not show a PASRR Level II evaluation or completion. During interviews, the Social Services Director stated they did not see a PASRR Level II for the resident and would need to look in the system, and the DON stated the Level II was not done because the resident came from another facility and staff assumed it had been completed. The facility policy stated that the nursing facility is responsible for ensuring a Level I screening is completed and a Level II is obtained if indicated on or before admission.
PASRR Screening Not Accurately Completed
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately completed for one resident reviewed for behavioral health management. The resident was admitted with a diagnosis of depression, and the admission record documented depression as an active diagnosis on admission. However, the PASRR completed on admission did not identify depression disorder under mental illness or suspected mental illness in Section I of the PASRR screen decision-making. Additional record review showed a physician order for mirtazapine with a diagnosis of depression unspecified, and a later psychiatry note documented depression and anxiety. During interviews, the DON stated the resident's PASRR was incorrect and that the admission department was responsible for checking accuracy, with social services responsible for submitting a new PASRR if needed. The Social Service Director stated the resident should have had an updated PASRR upon admission to include the depressive diagnosis. The facility policy stated the nursing facility is responsible for ensuring a Level I screening is completed, submitted, and has a Level I determination and/or Level II if indicated on or before nursing home admission.
Missed Wound Dressing Changes
Penalty
Summary
The facility failed to provide wound care dressing changes within professional standards of practice for 2 residents reviewed for wound care. Resident #127, who had diagnoses including asthma, prior TIA and stroke without residual deficits, history of venous thrombosis and embolism, COPD, hyperlipidemia, atherosclerotic heart disease, convulsions, and hypertension, was observed in bed with a dressing on the chin dated 9/13/2025. Her physician order dated 9/9/2025 directed daily dressing changes to cleanse with normal saline, pat dry, and cover with a dry dressing, and the TAR documented a dressing change on 9/14/2025. During interview, an LPN verified the dressing date and stated it should have been changed because it was ordered daily. Resident #92 was observed sitting in a wheelchair and later getting ready for transport with dressings on both lower legs dated 9/12/25. Physician orders dated 9/5/2025 directed dressing changes every other day and as needed for arterial wounds on both lower legs, with cleansing using normal saline, drying with gauze, applying skin prep and collagen powder, and covering with foam dressing. Progress notes from 9/14/2025 did not document any attempts to do dressing changes. An LPN stated she did not recall what happened on Sunday and that if the system did not show a dressing change was due, she would not know the resident had wound care due. The DON stated staff should be doing dressing changes as ordered and as needed, and if the dressing was done earlier, it should also be changed as scheduled and when needed.
Improper PICC and Midline Catheter Care During IV Medication Administration
Penalty
Summary
The facility failed to ensure PICC and midline catheter care was completed according to professional standards for two residents receiving IV therapy. One resident had diagnoses including osteomyelitis of the lumbar vertebrae, diabetes, heart failure, hypertension, anemia, hypothyroidism, depression, and adult failure to thrive. The resident had a left upper arm single-lumen PICC line with a transparent dressing dated 9/10/2025, and during observation the dressing edges were lifting on all sides and the insertion site was exposed to air. During medication administration for this resident, an LPN cleaned the needleless connector for 1 second with alcohol, did not allow it to dry, and immediately administered normal saline followed by heparin. The LPN did not attempt to verify PICC placement by aspirating for blood return before giving medications. In interview, the LPN stated the port should have been cleaned longer, placement was not verified, blood return was not checked, and the dressing should have been changed. The DON stated staff should follow the policy for administering medications in a central line. A second resident had diagnoses including acute pyelonephritis, diabetes with neuropathy, obstructive and reflux uropathy, sepsis, UTI, and ESBL resistance, and had a right upper arm midline catheter for meropenem therapy. During medication administration, the same LPN scrubbed the needleless connector for 1 second, did not allow it to dry, and immediately administered normal saline and attached the IV antibiotic. The LPN again did not attempt to verify catheter placement by aspirating for blood return. The LPN stated the connector should have been cleaned longer and placement should have been verified. Facility policy required vigorous cleansing of the needleless connector, allowing it to air dry, and verifying catheter patency with positive blood return before medication administration.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted accurately on a daily basis. During an observation on 9/15/25 at 9:00 AM, the nurse staffing information was posted and dated for 9/12/25, and the same outdated posting was still present during another observation later that day at approximately 3:00 PM. During an interview on 9/16/25 at 11:20 AM, the Administrator stated that the posting had not been updated and that the expectation was for staffing to be posted daily, noting it was in the process of being updated.
Unnecessary Medication Administration Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not following ordered parameters for Midodrine administration for 2 residents reviewed for unnecessary medications. For Resident #152, the physician order dated 03/30/2022 directed Midodrine 5 mg with instructions to hold for systolic blood pressure greater than 120 and not to give after 6:00 PM. The July, August, and September 2025 MARs documented multiple administrations when the resident's systolic blood pressure was above 120, including readings of 123/64, 122/70, 129/71, 128/79, 127/87, 122/70, 128/78, 122/60, 122/78, 121/57, and 129/69. The MAR also documented holds when the systolic blood pressure was below 120, including 116/70 and 104/60. Resident #152's record showed diagnoses including hypotension, essential hypertension, and unspecified intellectual disabilities, and the MDS documented a BIMS score of 03. For Resident #62, the physician order dated 9/5/2024 directed Midodrine 10 mg twice daily with instructions to hold for systolic blood pressure greater than 130. The September 2025 MAR documented the medication was given when systolic blood pressure was 142, 140, 144, and 135. During interviews, Staff A, RN, stated he administered Midodrine at 6:00 PM on 9/14/2025 and should have held it because the systolic blood pressure was outside the ordered parameter. Staff C, LPN, stated she gave the medication if her name was on the MAR, and Staff G, LPN, stated that if her name was on the MAR and it documented she gave it, then she did give it. The DON stated that nursing staff were expected to check residents' blood pressure and follow physician orders and parameters when giving medication.
Incomplete and inaccurate medication and pain documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for pain management and midodrine administration for three residents. For one resident, the physician ordered pain assessment every shift and oxycodone 10 mg as needed for severe pain, but the MAR showed multiple as-needed doses given when the resident reported pain levels of 5, 6, 7, or 8 while the General Administration History documented a pain level of 0 for the same shift. The MAR also showed several scheduled oxycodone administrations documented as late or charted late, and staff stated they were not consistently completing the pain assessment at the end of shift or documenting medication administration accurately. For another resident, the physician ordered midodrine 10 mg twice daily with instructions to hold for systolic blood pressure greater than 130. The MAR documented midodrine as given on multiple occasions when the recorded systolic blood pressure was above the hold parameter, including readings of 142, 140, 144, and 135. Staff stated they may have clicked medications as given before checking the blood pressure or may have documented the medication as given when it should have been held. The DON stated nurses were expected to check blood pressure before prepping the medication and documentation should be accurate. For a third resident, the physician ordered midodrine 5 mg with instructions not to give after 6:00 PM and to hold for systolic blood pressure greater than 120. Review of the MAR from July through September 2025 showed multiple instances where midodrine documentation was not accurate, including entries with no blood pressure documented and one entry showing blood pressure 122/76 with the medication documented as given. The resident had a BIMS score of 03 and diagnoses including hypotension, hypertension, peripheral vascular disease, osteoporosis, incontinence, and intellectual deficits. Staff stated they believed the medication had been given if it was charted as such, but also acknowledged the possibility of documenting the wrong blood pressure, and the DON stated she expected nurses to follow physician orders and document correctly when medications were held.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that resident assessments were completed accurately, specifically regarding the discharge status of a resident. Resident #158 was discharged on April 2, 2024, to a skilled nursing facility (SNF) out of state, as per the physician's order and discharge instructions. However, the Minimum Data Set (MDS) for the resident incorrectly recorded the discharge status as being to a short-term general hospital. This error was identified during interviews with the Long Term Care MDS Coordinator and another MDS Coordinator, who both confirmed that the discharge status should have been coded as a transfer to a SNF, not a hospital.
Failure to Complete PASRR for Resident Transitioning to Long-Term Care
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) for a resident who was initially admitted for respite care and later transitioned to long-term care. The resident, who had diagnoses including unspecified dementia, depression, brief psychotic disorder, and mood disorder due to a known physiological condition, was admitted for a respite stay. The PASRR Evaluation Request was completed, but the medical chart lacked results for a Level I screen for serious mental illness and/or intellectual disability or related conditions. This oversight was identified during a review of the resident's medical chart and confirmed through interviews with facility staff. Staff C, a social worker, acknowledged that the resident's PASRR should have been updated when the decision was made to transition the resident from respite care to long-term care. The Director of Nursing also recognized that the PASRR was not correct and should have been addressed. The facility's policy requires that Level I Determinations be signed and dated by an RN at the time of admission, and the nursing facility is responsible for ensuring the completion and submission of Level I screenings. However, this process was not followed, leading to the deficiency.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to administer blood pressure medication according to the physician's orders for a resident diagnosed with hypotension. The physician's order specified that Midodrine HCL 5 mg should be held if the resident's systolic blood pressure exceeded 110. However, the Medication Administration Record (MAR) for June 2024 showed that the resident received the medication on multiple occasions despite having systolic blood pressure readings above the specified threshold, including readings of 120/80 and 122/80. Interviews with the Director of Nursing and an Advanced Practice Registered Nurse (APRN) revealed that the nursing staff did not adhere to the physician's parameters for holding the medication. The APRN acknowledged that the parameters were set conservatively due to the resident's age, but emphasized the importance of following them. The facility's policy on medication administration requires staff to verify the correct medication, dose, and parameters before administration, which was not followed in this case.
Failure to Adhere to Dietary Restrictions for Resident
Penalty
Summary
The facility failed to adhere to dietary restrictions for a resident, specifically regarding the use of straws, which were prohibited due to the resident's risk of choking and aspiration. During an observation, it was noted that the resident's lunch tray included drinks with straws, despite a clear order against their use. The resident's meal ticket and physician's order both specified 'no straws' due to the resident's facial weakness and poor dentition, which increased the risk of choking when using straws. The Speech Language Pathologist had recommended against the use of straws as a precautionary measure following a clinical evaluation and swallow study. Staff interviews revealed a lack of awareness and adherence to the dietary restrictions. A Registered Nurse admitted to not checking the meal ticket for straw restrictions and acknowledged the expectation for CNAs to read meal tickets. The Director of Nursing explained that therapy communications are supposed to be updated in the care plan by the unit manager, and serious orders are highlighted in the electronic medical record for CNAs. However, despite these protocols, the order for no straws was not followed, leading to the deficiency.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that foods were stored safely in three nourishment rooms, as observed during a tour conducted on June 24, 2024. In the East Hall nourishment room, there was no thermometer in the freezer compartment of the refrigerator, and an ice buildup was noted with a wire dangling from the ice. Similarly, in the North Hall nourishment room, the freezer compartment lacked a thermometer. In the South Hall nourishment room, there was no thermometer in both the freezer and cooling compartments of the refrigerator, and an ice buildup was observed in the freezer. Additionally, an undated individual pizza serving was found in the freezer. During an interview on the same day, the Certified Dietary Manager confirmed the absence of thermometers in the nourishment room refrigerators and acknowledged the need for defrosting in the East and South Hall freezer compartments. The manager also recognized that the individual pizza serving in the South Hall refrigerator was undated. The facility's policy on leftover food storage and use, last reviewed on January 18, 2024, requires leftover foods to be covered, labeled, and dated, and used within 72 hours. The policy on food storage temperature logs mandates that temperatures be monitored and recorded to prevent foodborne illnesses.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to deficiencies in medication administration and pain management documentation. For Resident #12, the facility did not accurately document pain levels as required by the physician's order. Despite receiving pain medication, the resident's pain level was consistently recorded as zero, contradicting progress notes indicating the resident experienced pain and required morphine. The Director of Nursing acknowledged that the nursing staff should have documented the highest level of pain at the end of each shift, as per the facility's pain management policy. For Resident #39, there was confusion and inconsistency in the administration of insulin due to conflicting physician orders. The resident had two active insulin orders, one for Novolog and another for Novolin R, both intended for blood glucose levels over 399 mg/dl. The MAR showed instances where insulin was administered without documenting the corresponding blood glucose readings, and there was no clear documentation to justify the deviation from the active orders. Interviews with the Director of Nursing and nursing staff revealed that the orders were confusing, and the staff relied on verbal communication and common knowledge rather than clear documentation. The facility's policy on charting and documentation emphasizes the importance of accurate and complete documentation of residents' care, including medication administration and responses. However, the lack of clear documentation and adherence to physician orders for both residents highlights a significant deficiency in maintaining accurate medical records. This failure to document appropriately could impact the residents' treatment and care, as evidenced by the discrepancies in pain management and insulin administration.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing direct care to residents on transmission-based precautions. Specifically, a Certified Nursing Assistant (CNA) was observed not wearing eye protection while interacting with two residents who were positive for COVID-19. Despite the facility's policy requiring the use of gowns, face masks, eye protection, and gloves for COVID-19 positive rooms, the CNA admitted to not wearing a face shield or goggles, acknowledging the oversight during an interview. The Director of Nursing confirmed that staff should adhere to these PPE requirements. Additionally, the facility did not adhere to infection control standards regarding the cleaning of multi-use medical equipment. An LPN was observed using a blood pressure cuff on multiple residents without sanitizing it between uses. The LPN acknowledged the lapse, citing a lack of sanitizing wipes in the medication cart. Furthermore, another LPN placed tissues on an unsanitized bedside table and used them for a resident, contrary to the facility's policy of sanitizing surfaces or using barriers. The facility also failed to clean medication syringes after use, as observed with an LPN administering medication via a gastric tube. The LPN did not clean the syringe after administration, intending to do so later, which was against the facility's policy. The Director of Nursing confirmed that staff should clean reusable medical equipment between uses and sanitize surfaces before placing items on them. These deficiencies highlight lapses in following established infection control protocols, potentially increasing the risk of infection spread.
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 124 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Arbor Springs | 0.2 mi | ★★★★★ | 15 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Avante At Ocala, Inc | 0.9 mi | ★★★★★ | 27 | 0 |
| Palm Garden Of Ocala | 2.9 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Ocala | 3.1 mi | ★★★★★ | 8 | 0 |
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