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 Palm Garden Of Vero Beach during CMS and state inspections, most recent first.
A resident admitted after a hospital stay did not have a signed admission Agreement in the EMR, resulting in no documented written notice of rights, services, or charges. The Director of Guest Services described a standard process of assessing cognition, reviewing the Agreement with the resident or representative, and obtaining a signature within about 72 hours, but could not locate a completed Agreement for this resident and noted she had been the only Guest Services staff and was on vacation around the time of admission. A blank Agreement reviewed by surveyors showed that non‑covered service prices auto‑populate when the form is completed. The BOM and SSD confirmed that written information on room rates and non‑covered costs is contained in the admission Agreement and acknowledged that, for this resident, they only discussed costs verbally with the resident and her daughter, without any written documentation.
The facility failed to ensure timely specialist follow-up and accurate monitoring during changes in condition. A resident discharged from the hospital after an orthopedic procedure had discharge instructions for a follow-up orthopedic appointment in two weeks, but the appointment was not ordered until more than two weeks after admission and did not occur until about four weeks post-procedure, with no documented reason for the delay. Additionally, three residents who developed shortness of breath and were later hospitalized had Change in Condition forms that recorded vital signs taken many hours before the onset of symptoms instead of current BP, pulse, respirations, and O2 saturation at the time of the change, contrary to the facility’s stated assessment process.
Multiple air vents throughout therapy areas and hallways were found with black or rust-like staining, and several ceiling tiles and cabinets showed water damage and mold-like substances. A resident and therapy staff reported awareness of the dirty vents and musty, moldy odors, with staff also experiencing respiratory illnesses. Despite documented weekly vent checks and previous maintenance work orders, the observed environmental deficiencies persisted, indicating a failure to maintain a safe and clean environment.
The facility's Automatic Fire Sprinkler System (AFSS) was found to have multiple deficiencies during an inspection. Issues included a failure to report water flow to the fire panel, loaded sprinkler heads, and missing documentation for repairs. Observations also noted wires on sprinkler piping, paint on deflectors, and missing equipment in various rooms. These findings were acknowledged by the Director of Plant Operations.
The facility did not install a clean agent fire extinguisher in the Telecommunication Equipment Room, as required by NFPA 101 standards. This deficiency was observed during a fire safety tour, and the Plant Operations Technician acknowledged the issue. The absence of the extinguisher was discussed with the Administrator and Director of Plant Operations.
The facility failed to maintain fire/smoke barrier construction as per NFPA 101 standards. During a fire safety tour, several penetrations were found in the smoke barriers of the Reflection and Seaway Wings, compromising their fire resistance integrity. The Plant Operations Technician acknowledged these findings, which were communicated to the Administrator and Director of Plant Operations.
The facility failed to comply with NFPA 101 smoking regulations as the smoking area near Room 349 lacked a metal container with a self-closing lid and a safe, noncombustible ashtray. These deficiencies were observed during a fire safety tour with the Director of Plant Operations, who acknowledged the findings. The issues were discussed with the Administrator and Director of Plant Operations during the exit conference.
The facility failed to inspect and maintain its fire-rated attic access doors according to NFPA 101 standards. During a fire safety tour, it was found that these doors were not included in the annual inspection, and the Plant Operations Technician was unsure of their inspection status. The Director of Plant Operations confirmed the oversight, acknowledging the findings during an exit conference.
The facility did not maintain its security management plan as per NFPA 99 standards, failing to conduct an annual security vulnerability assessment. The last assessment was dated over a year ago, and this deficiency was acknowledged by the Director of Plant Operations during a record review.
The facility's Emergency Preparedness Program lacked policies for using volunteers and integrating State and Federally designated health care professionals during emergencies. This deficiency was identified during a record review and confirmed by the Administrator, highlighting a gap in the facility's emergency staffing strategies.
The facility failed to maintain egress doors in compliance with NFPA 101 standards. Observations during a fire safety tour revealed issues such as malfunctioning electronic access-controlled doors, missing signage on delayed egress doors, and excessive force required to open a Physical Therapy exit door. These deficiencies were acknowledged by the Plant Operations Technician and communicated to the facility's administration.
The facility was found non-compliant with NFPA 101 standards as eight doors with self-closing devices were either missing door closers or held open with magnets not connected to the fire alarm system. These issues were identified during a fire safety tour and acknowledged by the Plant Operations Technician.
The facility failed to provide timely medication and adhere to care plans for several residents, resulting in missed doses and improper wound care. A resident experienced delays in receiving medications, while another had a medical device improperly managed. Additionally, a resident wore socks against physician orders, and another did not receive proper wound care. A resident received treatment without a physician's order, highlighting documentation and oversight issues.
A LTC facility failed to provide timely medication and treatment for three residents. One resident missed doses of prescribed medications due to delays in administration despite availability. Another resident did not receive proper treatment for a skin condition, with staff deviating from physician orders. A third resident had a skin tear treated without a physician's order, indicating a lack of proper documentation and adherence to care standards.
A resident with a pressure injury on the left heel was observed wearing socks despite a physician's order to allow the heel to air dry. The resident, dependent on assistance for lower body care, expressed discomfort, and heel protectors were found unused on the floor. Staff A, a wound care nurse, applied socks after treatment, failing to provide necessary guidance on the risks, until the surveyor intervened.
The facility failed to provide appropriate care for two residents, leading to deficiencies in catheter management and hygiene care. A resident with an indwelling catheter had unsecured tubing and cloudy urine, which was not reported to a physician. Another resident received improper hygiene care, with inadequate cleaning and drying techniques. These issues highlight the need for improved staff training and adherence to care protocols.
A facility failed to discontinue medications for a resident as per the physician's orders following a pharmacy recommendation. Despite the physician accepting the recommendation to stop certain medications, the resident's active orders and Medication Administration Record (MAR) showed continued administration of these medications. The Director of Nursing (DON) indicated that the Unit Manager was responsible for updating the orders.
The facility failed to promptly initiate Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for residents diagnosed with multidrug-resistant organisms (MDROs), resulting in delays for several residents. A resident experienced a four-day delay in TBP initiation after an ESBL diagnosis, while another had a one-day delay. Additionally, a resident did not have the required contact precautions signage posted. The facility also lacked documented competency assessments or in-service training for staff on infection control practices.
Failure to Provide Written Admission Agreement and Cost Information
Penalty
Summary
The facility failed to provide a signed admission Agreement that included a written notice of resident rights, services, and charges for one resident. Record review showed that this resident was admitted following a hospital stay, but the resident’s file did not contain any signed admission Agreement. During a side‑by‑side record review and interview, the Director of Guest Services described the usual process for obtaining a signed admission Agreement, which involved assessing the resident’s cognition or checking a BIMS score, then reviewing and signing the Agreement with the resident if cognitively intact, or with a POA, spouse, or other family member if not. She stated this was typically completed within about 72 hours, depending on family availability, and that the Agreement could be executed via electronic signature. A blank admission Agreement reviewed during the survey did not have prices for non‑covered services filled in, and the Director of Guest Services explained that when she populated the form with the date, the prices and costs of services would automatically populate. When asked to locate the signed admission Agreement for this resident, the Director of Guest Services searched the EMR and confirmed there was none, stating she did not know what happened but recalled she was the only person in Guest Services at the time and had taken a vacation during that period. When questioned about written notice of costs for services not covered once the resident’s benefits ended, the Director of Guest Services stated that the resident or representative would have had a conversation with the Business Office Manager (BOM) and/or Social Services Director (SSD). In a separate interview, the BOM and SSD stated that written information about room rates and non‑covered costs was contained in the admission Agreement and acknowledged that, for this resident, they had only verbal conversations with the resident and her daughter about costs, with no documentation of written notice.
Failure to Ensure Timely Specialist Follow-Up and Accurate Change-in-Condition Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate care and services in accordance with physician orders and residents’ needs. One resident was admitted following an orthopedic procedure with hospital discharge instructions specifying a follow-up appointment with the orthopedic surgeon in two weeks and directing staff to call for an appointment. The record showed that the order for this follow-up appointment was not entered until seventeen days after admission, and the actual orthopedic follow-up visit did not occur until four weeks after the procedure. There was no documentation in the record explaining the delay. During interview, the scheduling clerk reported difficulty obtaining appointments with this orthopedic surgeon and stated that if the surgeon was booked, they would seek a verbal order for the wound care nurse to remove staples if needed, but confirmed there was no documentation explaining the delayed appointment for this resident. The deficiency also includes failures to thoroughly monitor and assess residents experiencing a change in condition related to shortness of breath. For three residents who were later hospitalized, the facility’s Change in Condition forms documented shortness of breath beginning that night or that morning, but the vital signs recorded on those forms were taken many hours earlier and not at the time of the reported change. In one case, the form for a resident with shortness of breath documented blood pressure, pulse, and temperature from approximately ten hours before the event. In another case, the form for a resident with shortness of breath used blood pressure and oxygen saturation from early that morning and a temperature from late that afternoon, rather than at the time of the change. In the third case, the form for a resident with shortness of breath documented a pulse obtained several hours earlier the previous night. The Clinical Services Coordinator stated that the process for a change in condition should include a head-to-toe assessment and a full set of current vital signs (blood pressure, pulse, respirations, and oxygen saturation) entered into the EMR, and agreed with the findings when made aware of the discrepancies.
Failure to Maintain Clean and Safe Environment Due to Unaddressed Mold and Water Damage
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by multiple air vents with black colored substances or rust-like staining, water-stained ceiling tiles, and sink cabinets with offensive odors and visible mold-like substances. During a facility tour, surveyors observed these conditions throughout the therapy area, Reflection Hallway, and various therapy offices. The therapy gym, occupational therapy area, speech therapy office, and physical therapy charting room all had vents with black or rust-like stains, and the cabinet beneath the handwashing sink in the therapy area emitted a strong musty, moldy odor with visible black substances and water stains. Water damage was also noted on the ceiling in the Reflection Hallway and around the sprinkler head in the Speech Therapy office. Interviews with residents and staff confirmed awareness of the environmental issues. A resident receiving therapy commented on the need for vent cleaning, while therapy staff reported experiencing multiple respiratory illnesses in recent months, attributing these to environmental factors such as musty and moldy smells, especially when the air conditioner was off. Staff also noted the presence of black substances on vents in the therapy gym and smaller rooms. The Rehab Director acknowledged the black substances and reported them through the facility's maintenance system, but was unaware of staff respiratory issues. The Maintenance Director stated that a new roof installation was underway, causing debris and dust, and that while housekeeping dusted vents, maintenance was responsible for deeper cleaning. However, no testing had been conducted on the black substances, and routine vent checks were documented as completed, despite the observed deficiencies. Review of maintenance logs revealed previous work orders addressing similar issues, such as suspected mold and termite pellets under the PT gym sink and requests to address black spots and stains around duct areas. Despite documentation that these work orders were completed, the conditions persisted at the time of the survey. The maintenance log lacked details on what actions were taken, and the observed deficiencies remained unresolved, indicating a failure to ensure a safe and clean environment as required.
Deficiencies in Fire Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 standards. During an inspection on April 30, 2025, it was discovered that the annual AFSS inspection conducted on February 17, 2025, identified deficiencies, specifically that the water flow was not reporting to the fire panel. No documentation was provided to show that this deficiency had been repaired. This issue was acknowledged by the Director of Plant Operations during the review. Further observations during the fire safety tour revealed multiple issues with the sprinkler system. At the Reflections Nurses Station, a white wire was found laying on top of the AFSS piping. In the Reflections Television Cable Room, a fire sprinkler head was loaded with paint on the deflector. The Kitchen had two out of three loaded dry sprinkler heads in the walk-in coolers, and the Beauty Supply Room had one of two loaded fire sprinkler heads. Additionally, the Phone Room in the Laundry corridor had a sprinkler surrounded by a ceiling with open seams, exposing the interstitial space above. Additional deficiencies included a red tag in the Fire Riser Room indicating the water flow issue, an illegible hydraulic design calculation sign, and a missing spare concealed sprinkler wrench. Insulation was found on top of the sprinkler piping near Room 206 in the Seaway Wing. The Physical Therapy Riser Room's spare sprinkler head box lacked a list of spare fire sprinkler heads, and the Independent Wing Riser Room had an illegible hydraulic design sign. These findings were acknowledged by the Director of Plant Operations and explained to the Administrator during the exit conference.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the Independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the Independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review.
Failure to Install Clean Agent Fire Extinguisher in Telecom Room
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the installation and maintenance of portable fire extinguishers. During a fire safety tour conducted on April 30, 2025, it was observed that the Telecommunication Equipment Room, located next to the Culinary Director's Office, did not have a clean agent fire extinguisher installed. This observation was made in the presence of the Plant Operations Technician, who acknowledged the deficiency. The absence of a clean agent fire extinguisher in the Telecommunication Equipment Room was discussed with the Administrator and the Director of Plant Operations during the exit conference on the same day. The deficiency was noted as a failure to adhere to the requirements outlined in NFPA 10 and NFPA 101, which specify the selection, installation, inspection, and maintenance of portable fire extinguishers in such areas.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K355. The telecommunication Equipment Room, located next to the Culinary Director's Office, had a clean agent fire extinguisher ordered on 05/16/2025 by the maintenance director/designee. Fire extinguishers will be audited weekly x4 weeks and monthly x6 months for compliance with K355 by the maintenance director/designee. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review.
Deficiencies in Fire/Smoke Barrier Construction
Penalty
Summary
The facility failed to maintain their fire/smoke barrier construction in accordance with NFPA 101 standards. During a fire safety tour conducted on April 30, 2025, several deficiencies were observed in the smoke barriers of the facility. Specifically, the Reflection Wing's 1-hour smoke wall near Room 106 had five penetrations above the ceiling, and near Room 104, there were three penetrations. Additionally, the Seaway Wing's 2-hour fire-rated wall near Room 206 had four penetrations above the ceiling. These penetrations in the smoke barriers compromise the integrity of the fire resistance rating, which is crucial for restricting the movement of fire and smoke in the event of an emergency. The Plant Operations Technician acknowledged these findings during the inspection, and the issues were communicated to the Administrator and the Director of Plant Operations during the exit conference. The report emphasizes that these examples are not exhaustive, and a thorough inspection of each barrier should be conducted to ensure all penetrations are identified and properly sealed. The penetrations in fire-rated barriers must be sealed with a UL-listed approved system to restore the original fire or smoke-rated integrity of the walls, ceilings, and floors.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K372. The center smoke walls were inspected above the ceilings throughout the center on 05/16/2025 to identify any other penetrations needing to be sealed by the maintenance director/designee. 1. The Reflection Wing 1-hour smoke wall, near Room 106, had the five penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 2. The Reflection Wing 1-hour smoke wall, near Room 104, had the three penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 3. The Seaway Wing 2-hour fire rated wall, near Room 206, had the four penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. Fire penetrations above the ceiling will be audited for compliance with K372 by the maintenance director/designee weekly x4 weeks, monthly x6 months and the results of these audits will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K372. The center smoke walls were inspected above the ceilings throughout the center on 05/16/2025 to identify any other penetrations needing to be sealed by the maintenance director/designee. 1. The Reflection Wing 1-hour smoke wall, near Room 106, had the five penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 2. The Reflection Wing 1-hour smoke wall, near Room 104, had the three penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. 3. The Seaway Wing 2-hour fire rated wall, near Room 206, had the four penetrations above the ceiling repaired on 05/20/25 by the maintenance director/designee. Fire penetrations above the ceiling will be audited for compliance with K372 by the maintenance director/designee weekly x4 weeks, monthly x6 months and the results of these audits will be brought to QAPI for review.
Non-compliance with NFPA 101 Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations during a fire safety tour. Specifically, the smoking area near Room 349 lacked a metal container with a self-closing lid for ashtrays to be emptied into, and there was no ashtray of a safe, noncombustible design available. These deficiencies were observed on April 30, 2025, at 4:43 PM, during an inspection conducted with the Director of Plant Operations. The Director of Plant Operations acknowledged the findings during an interview conducted concurrently with the observations. The deficiencies were further explained to both the Administrator and the Director of Plant Operations during the exit conference held on the same day at 6:30 PM. The report highlights the facility's failure to maintain the smoking area in accordance with the specified safety standards, which is a requirement under NFPA 101 (2021 Edition) 19.7.4 (5-6).
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K741. The smoking equipment was removed on 05/16/2025 by the maintenance director/designee as the center is a smoke free facility with no residents who smoke living in it. The center will maintain the smoke free policy. Any changes in this policy would be brought to the QAPI committee for review.
Failure to Inspect Fire-Rated Attic Access Doors
Penalty
Summary
The facility failed to inspect and maintain its fire doors in accordance with NFPA 101 standards, specifically for seven sampled fire-rated attic access doors. During a fire safety tour, it was observed that these doors were present, but the Plant Operations Technician was unsure if they were included in the annual fire door inspection. A review of the facility's records revealed that the annual fire door inspection conducted on April 10, 2025, did not include these attic access doors. Interviews with the Plant Operations Technician and the Director of Plant Operations confirmed the oversight, and they acknowledged the findings. The issue was discussed with the Administrator and the Director of Plant Operations during the exit conference. The report highlights that the facility did not comply with the required standards for fire door maintenance and inspection, as outlined in NFPA 101 and NFPA 80.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K761. The attic fire doors were inspected by the maintenance director/designee on 05/20/2025. No concerns were identified. The result of the inspection was brought to QAPI on 05/21/2025. Attic fire doors will be inspected annually per K761 by the maintenance director/designee and the results of the inspection will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K1150. The annual security vulnerability assessment was completed on 05/15/25 by the Executive Director. The assessment was brought to QAPI on 05/21/25 for review. The security vulnerability assessment will be reviewed annually per K1150 by the Executive Director and QAPI Committee.
Failure to Conduct Annual Security Vulnerability Assessment
Penalty
Summary
The facility failed to maintain its security management plan in accordance with NFPA 99 standards. During a record review conducted on April 30, 2025, it was found that the facility did not provide documentation of an annual security vulnerability assessment. The last assessment available was dated January 25, 2023, indicating that the required annual review had not been conducted. This deficiency was identified during a review with the Director of Plant Operations, who acknowledged the findings. The issue was also discussed with the Administrator and the Director of Plant Operations during the exit conference on the same day.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K1150. The annual security vulnerability assessment was completed on 05/15/25 by the Executive Director. The assessment was brought to QAPI on 05/21/25 for review. The security vulnerability assessment will be reviewed annually per K1150 by the Executive Director and QAPI Committee.
Deficiency in Emergency Preparedness Program
Penalty
Summary
The facility failed to incorporate the use of volunteers and other emergency staffing strategies in their Emergency Preparedness Program (EP) as required by the Code of Federal Regulations (CFR). During a record review conducted on April 30, 2025, it was found that the facility's EP lacked policies and procedures detailing the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a review of the facility's documentation with the Administrator. An interview with the Administrator, conducted concurrently with the record review, confirmed the absence of these critical policies and procedures. The Administrator acknowledged the findings, which were subsequently reviewed with both the Administrator and the Director of Plant Operations during the exit conference on the same day. The lack of a comprehensive plan for utilizing volunteers and integrating designated health care professionals during emergencies represents a significant gap in the facility's emergency preparedness efforts.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The Executive Director was educated by the Regional Director of Operations on 05/16/2025 regarding E024. The policy for E024 was updated by the Executive Director on 05/16/2025 to reflect the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The policy was approved by the QAPI committee on 05/21/2025. The policy will be maintained in the Executive Director's office and reviewed annually or as needed.
Egress Door Deficiencies in Facility
Penalty
Summary
The facility failed to maintain egress doors equipped with special locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, several deficiencies were observed. At the main entrance, the electronic access-controlled double horizontal sliding exit doors' right leaf did not break away when tested, indicating a malfunction in the emergency egress system. Additionally, the reception interior-egress door and smoke doors near Room 106, both equipped with delayed egress locking arrangements, were missing the required signage, which is essential for proper identification and operation during emergencies. Further observations revealed that the corridor doors leading to the laundry area, also equipped with delayed egress locking arrangements, were missing the necessary signage and automatically reset when tested, which could hinder emergency evacuation. The Physical Therapy exit door required more than fifteen pounds of force to open due to the threshold rubbing on the bottom of the door, which is a violation of the force requirements for egress doors. These issues were acknowledged by the Plant Operations Technician during the survey. The findings were communicated to the Administrator and the Director of Plant Operations during the exit conference. The report highlights the facility's failure to comply with NFPA 101 standards for egress doors, which are critical for ensuring safe and efficient evacuation during emergencies. Photographic evidence was obtained to support these findings.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated on K222 on 05/16/2025 by the Executive Director. The maintenance director/designee completed the following corrections to the delayed egress doors: 1. The Main Entrance electronic access-controlled double horizontal sliding exit doors was inspected on 05/16/25 and the center obtained a quote to repair the lock on the door. The lock will be repaired by 05/24/2025. There is an existing fire exit on the left side of the door as of 05/16/2025. 2. The Reception interior-egress door has signage added to include the egress time on 05/22/2025. 3. The smoke doors equipped with a delayed egress locking arrangement, near Room 106 had the signage added to the doors on 05/22/2025. The maglock was inspected on 05/16/2025 by a vendor to re-engage the maglock and the egress door will be able to show functionality by 05/24/2025. 4. The corridor doors leading to laundry equipped with a delayed egress locking arrangement had the correct signage installed on 05/22/2025 and the reset was inspected by a vendor on 05/16/2025 for proper functionality. 5. The Physical Therapy exit door, equipped with a delayed egress locking arrangement was corrected to open with less than 15 pounds of pressure on 05/15/2025. Delayed egress doors will be audited for proper functioning related to signage, breakaway, pressure and resetting weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review.
Non-compliance with NFPA 101: Self-Closing Door Devices
Penalty
Summary
The facility failed to maintain doors with self-closing devices in accordance with NFPA 101 standards. During a fire safety tour on April 30, 2025, it was observed that eight out of twenty-nine sampled doors with self-closing devices were not compliant. Specifically, the Beauty Supply Room and the Life Enrichment Dining Room doors were missing door closers. Additionally, several office doors, including those of the Culinary Director, Social Services, Director of Utilization, Physical Therapy, Seaway Wing Office, and Seaway Wing Clinical Services, were held open with magnets that were not connected to the fire alarm system. These deficiencies were identified during a walkthrough with the Plant Operations Technician/Director of Plant Operations, who acknowledged the findings. The issues were discussed with the Administrator and the Director of Plant Operations during the exit conference. Photographic evidence was obtained to support the observations, and the findings were documented as a Class III deficiency under NFPA 101 standards.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K223. 1. The Beauty Supply Room 45-minute fire door, open to the corridor, was repaired and a closer was added on 05/16/2025. 2. The Culinary Director Office door, open to the corridor, had a closer added and the magnet was removed from the door frame on 05/16/2025. 3. The Social Services Office door, open to the corridor, had the magnet removed on 05/16/2025. 4. The Director of Utilization Office door, open to the corridor, had the magnet removed on 05/16/2025. 5. The Physical Therapy door, open to the corridor, had the magnet removed on 05/16/2025. 6. The Seaway Wing Office 90-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 7. The Seaway Wing Clinical Services 45-minute fire rated door, open to the corridor, the magnet was removed on 05/16/2025. 8. The Life Enrichment Dining Room door, open to the corridor, had a door closer installed on 05/16/2025. Doors with self-closing devices will be audited weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review.
Medication and Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure timely and appropriate quality of care for several residents, as evidenced by multiple medication administration errors and lack of adherence to physician orders. For instance, Resident #24 experienced delays in receiving prescribed medications, including Lumigan and other essential drugs, due to staff awaiting delivery, resulting in missed doses. The Unit Manager was unable to provide a reason for the delay, despite the medications being available in the facility's emergency stock. Resident #162's care was compromised due to improper management of a medical device, as staff failed to secure tubing properly, leading to potential complications. Observations revealed cloudy fluid in the tubing, which was not addressed by the LPN, who admitted to not notifying the physician about the issue. The Unit Manager acknowledged the delay in reviewing lab results and obtaining necessary orders, which contributed to the inadequate care provided. Additionally, Resident #100's care plan was not followed, as staff allowed the resident to wear socks against physician orders, which could hinder the healing of a pressure injury. Staff failed to educate the resident on the importance of adhering to the care plan. Furthermore, Resident #102 did not receive proper wound care as per physician instructions, with observations showing uncovered wounds and improper dressing changes. Lastly, Resident #517 received treatment for a skin tear without a physician's order, indicating a lack of proper documentation and oversight in the facility's care processes.
Plan Of Correction
Resident #24 completed her on, on and per the podiatrist. On she had no signs of. Per the orthopedic surgeon on the resident s healed and there were no concerns documented. The resident received her as ordered on and discharged from the center on. Resident #102 will have his care completed per the physician orders. The for resident #517 has resolved. Resident #517 will have his care completed per physician orders. Resident #100 receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent and prevent new from developing. The resident #162 had her changed and recollected on. Her bag will be anchored as required. Her will be ordered in a timely manner. Resident #11 will have her completed per the center's process. Residents with and orders were audited on to ensure that their or were administered per physician orders. No other residents were affected by this alleged deficient practice. Residents with will have their care completed per physician orders. Care orders were audited to ensure no other residents were affected by this alleged deficient practice. Residents with were observed on to ensure proper control practices were followed. No residents were affected by this alleged deficient practice. Residents with or will have or care observations completed by the Director of Education/designee to ensure clinical competency for this standard of practice. Any lack of competency by the team member will be corrected immediately. Residents pending results had their results reviewed on ensure timely ordering of. Any results with a delay in treatment will result in a physician notification. The director of education or designee will complete the following educations for nursing team members by: a. Licensed nurses will be educated on following physician orders for care, and b. Licensed nurses will be educated to obtain a care order prior to providing a treatment. c. Licensed nurses will be educated on the signs and symptoms of a and to report laboratory results timely to the provider. d. Nursing team members will be educated on proper control procedures regarding. e. Certified nursing assistants will be educated on proper procedures. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the preventionist/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the DCS/designee. Care treatments will be audited for accuracy weekly x4 weeks and months x12 months by the DCS/designee. Results will be audited to ensure timely review and ordering of an weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Anchors will be audited weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Provided to residents with will be audited weekly x4 weeks and monthly x12 months by the director of clinical services/designee. All audits will be brought to the QAPI committee monthly for review.
Medication and Treatment Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely and appropriate quality of care for three residents, as evidenced by issues with medication administration and treatment orders. Resident #24 experienced delays in receiving prescribed medications, including Lumigan and other medications, due to staff awaiting delivery. Despite the medications being delivered, they were not administered timely, resulting in missed doses. The Unit Manager was unable to provide a reason for the delay in administration, and some medications that were available in the emergency stock were not utilized. Resident #102 did not receive treatment as per physician orders for a self-inflicted skin area on the right lateral lower leg. Observations revealed the area was uncovered and had bloody drainage, with staff unsure about the treatment status. The resident complained of itching from the gauze, and staff did not follow the prescribed treatment plan, opting instead to apply lotion without a physician's order. This inconsistency in care was confirmed through interviews with staff, who acknowledged the resident's tendency to scratch the area. Resident #517 had a skin tear on the left leg that was not documented with a physician's order for care. Observations showed the area was covered with a dressing, but there was no order for the treatment. Staff interviews revealed a lack of clarity on who applied the dressing, and the Unit Manager confirmed the absence of a physician order for the care of the skin tear. This oversight in documentation and treatment planning highlights a gap in the facility's adherence to professional standards of practice.
Plan Of Correction
Resident #24 completed her on on and per the podiatrist she had no signs of. Per the orthopedic surgeon on the residents healed and there were no concerns documented. The resident received her as ordered on and discharged from the center on. Resident #102 will have his care completed per the physician orders. The for resident #517 has resolved. Resident #517 will have his care completed per physician orders. Residents with and orders were audited on to ensure that their or were administered per physician orders. No other residents were affected by this alleged deficient practice. Residents with will have their care completed per physician orders. Care orders were audited on to ensure no other residents were affected by this alleged deficient practice. Licensed nurses will be educated on following physician orders for care, and by the Director of Education/designee. Licensed nurses will be educated to obtain a care order prior to providing a treatment by the Director of Education/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the preventionist/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the DCS/designee. Care treatments will be audited for accuracy weekly x4 weeks and months x12 months by the DCS/designee. All audits will be brought to QAPI monthly for review.
Failure to Follow Physician's Orders for Pressure Injury Care
Penalty
Summary
The facility failed to adhere to a physician's order regarding the care of a resident with a pressure injury on the left heel. The resident, who was moderately dependent on assistance for lower body care, was observed wearing socks despite a specific order to allow the heel to air dry and not to wear socks. The care plan included interventions such as floating the heels while in bed and applying treatment to the heel on specific days. However, observations revealed that the resident's heels were not properly off-loaded, and heel protectors were found on the floor instead of being used as intended. Staff A, a wound care nurse, applied socks to the resident's feet after treatment, contrary to the physician's order. The resident expressed discomfort, stating that her heels hurt, yet the staff did not provide guidance or education on the risks of wearing socks over the affected area. Despite a visitor's advice to remove the socks, the resident continued to wear them until the surveyor intervened. Staff A acknowledged the oversight and the importance of following the physician's order after being reminded by the surveyor.
Plan Of Correction
Resident #100 receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent and prevent new wounds from developing. Res #100 was educated on wearing socks and agreed to follow care recommendations. Res #100 has adequate pillows to off-load heels when in bed or when heels are in a dependent position. Nursing team members will remind Res #100 to keep heels off-loaded as recommended during care and daily interactions. Care orders were audited to ensure no other residents were affected by this alleged deficient practice. Residents with similar needs were observed to ensure proper control practices were followed. No residents were affected by this alleged deficient practice. Licensed nurses will be educated to follow physician orders related to care by the Director of Education/designee. Nursing team members will be educated on proper control procedures by the Director of Education/designee. Care orders will be audited to ensure they are completed per physician orders weekly for 4 weeks and monthly for 12 months by the Director of Clinical Services/designee. Proper control procedures will be audited for control placement weekly for 4 weeks and monthly for 12 months by the Director of Clinical Services/designee. All audits will be brought to the QAPI committee monthly for review.
Deficiencies in Catheter Management and Hygiene Care
Penalty
Summary
The facility failed to provide appropriate care and services for two residents, leading to deficiencies in their treatment. Resident #162 was admitted with an order for an indwelling catheter, which was not properly managed. Observations revealed that the catheter tubing was not securely anchored, causing it to pull tightly when the resident was repositioned. Additionally, the catheter bag contained cloudy urine, which was not reported to the physician by the LPN, despite acknowledging the issue. The Unit Manager confirmed a delay in reviewing lab results, which indicated a positive culture requiring antibiotic treatment. Resident #11, who was severely cognitively impaired and frequently incontinent, also received inadequate care. During a personal hygiene routine, a CNA used improper techniques, such as pouring water from a towel onto the resident's private area and failing to clean external structures thoroughly. The CNA did not dry the area before applying protective cream and securing a new adult brief. The Director of Nursing and the Infection Control Preventionist agreed that the care process was improperly executed after observing a demonstration of the CNA's actions. These deficiencies highlight the facility's failure to ensure proper catheter management and personal hygiene care for residents, as required by their comprehensive assessments. The lack of secure catheter anchoring and failure to address cloudy urine in Resident #162, along with the improper hygiene care for Resident #11, demonstrate a need for improved staff training and adherence to care protocols.
Plan Of Correction
Changed and recollected on. Her bag will be anchored as required. Her will be ordered in a timely manner. Resident #11 will have her completed per the center's process. Residents with or will have or care observations completed by the Director of Education/designee to ensure clinical competency for this standard of practice. Any lack of competency by the team member will be corrected immediately. Residents pending results will have their results reviewed timely to ensure timely ordering of. Any results with a delay in treatment will result in a physician notification. The director of education or designee will complete the following educations for nursing team members by. Licensed nurses will be educated on the signs and symptoms of a and to report laboratory results timely to the provider. Nursing team members will be educated on how to anchor a. Certified nursing assistants will be educated on proper procedures. Results will be audited to ensure timely review and ordering of an weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Anchors will be audited weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Provided to residents with be audited weekly x4 weeks and monthly x12 months by the director of clinical services/designee. All audits will be brought to the QAPI committee monthly for review.
Failure to Discontinue Medications as Per Physician's Orders
Penalty
Summary
The facility failed to ensure compliance with physicians' orders as recommended by the pharmacy for a resident. The resident was admitted to the facility and had a current Minimum Data Sheet (MDS) assessment score of 15. A pharmacy consultation report recommended discontinuing certain medications that promote gut health and normal functioning. The physician accepted this recommendation by signing the consultation. However, a review of the resident's active orders revealed that the medications were still being administered, as evidenced by the Medication Administration Record (MAR). The supplements were not discontinued as per the physician's orders, indicating a lapse in following through with the pharmacy's recommendations. During an interview, the Director of Nursing (DON) stated that the Unit Manager was responsible for making changes to the resident's orders after the doctor accepts or declines the pharmacy recommendation.
Plan Of Correction
Resident #48 had his discontinued on and Medication recommendations will be audited for of 2024 and the past 90 days to ensure compliance on by the DCS and facility pharmacist. If recommendations were identified as not followed through, they would be implemented at the time of the audit. The clinical services leadership team was educated on following pharmacy recommendations timely by the Regional Director of Clinical Services on. Pharmacy recommendations will be brought to QAPI monthly to review completion and for follow-up by the Director of clinical services/designee.
Delayed Implementation of Infection Control Precautions
Penalty
Summary
The facility failed to implement effective infection prevention and control practices, specifically in the timely initiation of Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for residents diagnosed with multidrug-resistant organisms (MDROs). The report highlights that four residents, who should have been placed on EBP and TBP, experienced delays in the initiation of these precautions. For instance, Resident #80 had a delay of four days in starting TBP after being diagnosed with extended-spectrum beta-lactamase (ESBL) bacteremia. Similarly, Resident #31 experienced a one-day delay in TBP initiation after an ESBL diagnosis. The report further details that Resident #6 had a two-day delay in starting EBP after being diagnosed with ESBL. Additionally, Resident #129, who was diagnosed with ESBL, did not have the required contact precautions signage posted on their door, indicating a lapse in the facility's adherence to its own infection control policies. These lapses were identified during a survey, and the facility's Infection Preventionist acknowledged the delays in implementing the necessary precautions. The facility's failure to provide appropriate education or ensure competency among staff regarding infection control practices was also noted. The Infection Preventionist admitted to not conducting documented competency assessments or in-service training related to infection control, which contributed to the deficiencies observed. The report indicates that the facility had been experiencing an increase in facility-acquired infections, yet there was a lack of documented evidence of corrective actions or staff education to address these issues.
Plan Of Correction
Appropriate control and/or isolation precautions were initiated for residents #129, #80, #31, and #6 on Residents on were audited on to ensure that the proper precautions were in place. If precautions were to be found missing they were initiated immediately. Licensed nurses will be educated on transmission based precautions and enhanced barrier precautions by the Director of Education/Preventionist/designee. Orders and precautions will be reviewed by a member of the clinical team daily to ensure that precautions are implemented timely. Orders and precaution signs will be audited weekly x4 weeks then monthly x12 months. The results of these audits will be brought to the QAPI committee monthly for review.
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 26 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
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 Vero Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vero Beach Care Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Sea Breeze Rehab And Nursing Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Hidden Lakes Senior Living Community | 0.8 mi | ★★★★★ | 12 | 0 |
| Garden View Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At Indian River Estates | 5.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.