Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palms At Sebring Nursing And Rehabilitation The during CMS and state inspections, most recent first.
A resident with an immunocompromised condition and other comorbidities had a standing order for daily Biktarvy, but the MAR and related notes showed multiple missed doses over two months because the medication was not available. Nursing staff documented that they were waiting for the resident or family to bring the medication from home and that insurance issues delayed refills, while several nurses and the interim DON stated the facility did not provide this antiretroviral drug due to its high cost and placed responsibility on the resident to supply it. The NHA described a process for reviewing high-cost medications and reported that a prior DON chose not to approve this medication, and the attending physician reported being informed the resident went without it for more than a week and stressed that it was a medication the resident had to take every day. The facility reported having no policy governing provision of antiretroviral medications.
Over a five-month period, the facility did not document or resolve repeated group grievances from the Resident Council regarding hydration and snack availability. Two cognitively intact residents confirmed that these concerns were discussed multiple times without any observed changes. The Activities Director admitted that group concerns were not entered into the grievance system, and the NHA was unaware of this practice, despite facility policy requiring all grievances to be documented and tracked.
The facility failed to provide the correct beneficiary notifications to three residents regarding changes in their skilled services and related coverage. Instead of issuing the required Notice of Medicare Non-coverage (NOMNC) to residents being discharged, the facility only provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). This issue arose following a directive from the Administrator to use a new SNF ABN form, leading to the omission of the NOMNC for discharged residents.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in documented care needs and diagnoses. A resident's dementia diagnosis was omitted, another's medication use was not marked, a third required more assistance than documented, and a fourth had unaddressed vision impairment. These oversights were acknowledged by staff.
The facility failed to accurately complete Level I PASRR forms for several residents, omitting key mental health and intellectual disability diagnoses. The DON acknowledged the inaccuracies, which were found in the PASRR forms of residents with conditions such as major depressive disorder, bipolar disorder, and schizophrenia. The facility's policy requires accurate PASRR completion, but this was not adhered to, leading to deficiencies in documentation.
The facility failed to develop and implement comprehensive care plans for five residents, resulting in unmet needs. A resident with tobacco use had no related care plan, while two residents requiring mechanical lifts were inaccurately assessed for partial assistance. Another resident with impaired vision lacked a care plan for vision loss, affecting her ability to identify meals. Additionally, a resident receiving hospice care had no care plan for these services. Staff interviews confirmed these deficiencies.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident with dementia had an outdated dining assistance plan, while another required more eating assistance than documented. A resident with skin impairment lacked a care plan for treatment, and a resident with aggressive behavior had no revised interventions. Additionally, a resident with a history of skin picking had no care plan updates. These issues highlight the facility's failure to adhere to its policy of updating care plans with changes in residents' conditions.
The facility failed to provide adequate care and treatment for several residents, including assistance with eating, proper assessment for transfers, timely notification of condition changes, pain management, and wound care. Residents were left unattended during meals, lacked necessary equipment like wheelchairs, and experienced delays in pain relief and wound treatment.
The facility failed to honor food preferences for several residents, leading to unmet dietary needs. A resident repeatedly requested hot tea but was not provided, while another with dental issues received food difficult to chew. A cognitively intact resident with malnutrition did not receive preferred breakfast items, and another resident noted missing condiments on meal trays. The facility's policy on food preferences was not effectively implemented.
The facility did not ensure simultaneous meal service for residents in the dining room, leading to delays and dignity issues. Observations showed residents at the same table were served at different times, with some waiting up to 21 minutes. Staff interviews revealed systemic issues with tray delivery, and the facility's policy on dignity was not upheld.
The facility failed to honor the advance directives of two residents, leading to significant deficiencies in their care. One resident, with an intellectual disability, was made to sign documents despite having a court-appointed guardian. Another resident, with cognitive impairments, was incorrectly listed as their own responsible party, despite needing a surrogate. Staff interviews revealed discrepancies and a lack of adherence to facility policies on advance directives.
The facility did not ensure the privacy of residents' health information on the East unit. Observations showed unattended medication carts with unlocked computer screens displaying medical records, and a lab book with a resident's face sheet visible at the nurses' station. Staff interviews confirmed awareness of privacy protocols, and the DON emphasized the importance of locking screens and securing papers.
A resident with multiple fractures developed new pressure wounds while in the facility, due to inconsistent wound care and preventive measures. The resident's wounds were not managed according to the facility's policy, with missed dressing changes and lack of an air mattress. The nursing staff acknowledged the challenges and deficiencies in care.
A resident was found with smoking materials in their room, unaware of the facility's smoking policy, and without a documented smoking evaluation or care plan. Additionally, razors and scissors were improperly stored in two resident rooms, with staff showing inconsistent understanding of the facility's policy on sharp objects. The facility lacked a formal policy on the prohibition of razors and scissors in resident rooms, relying instead on staff education.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease. Despite having a policy for AV-fistula-graft care, the facility did not utilize available options to record post-dialysis assessments in medical records. Nursing staff acknowledged the lack of documentation, and the DON was unaware of the documentation option.
The facility failed to complete pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident with heart disease had unaddressed recommendations for Peridex solution, while another with multiple psychiatric and medical conditions had unaddressed recommendations for Diclofenac gel, Midodrine, and Calcitonin Nasal solution. The DON admitted to missing these due to falling behind, and the facility lacked a policy for handling pharmacy recommendations.
The facility failed to properly secure medications, with multiple instances of unlocked and unattended medication carts and unsecured medications in resident rooms. Observations revealed medications left on top of carts and in resident rooms, contrary to the facility's policy requiring secured storage. Interviews with the Consultant Pharmacist and DON confirmed these practices were not in compliance with established procedures.
A facility failed to follow its antibiotic stewardship protocols for a resident receiving IV antibiotics for a severe UTI. The resident's physician orders lacked end dates for Vancomycin and Cefepime, contrary to the facility's policy requiring complete antibiotic orders. The DON acknowledged the oversight, noting that all antibiotics should have an end date for proper monitoring.
A resident was issued a 30-day discharge notice citing non-payment and improved health, despite not owing money and requiring continued care. The resident, who was cognitively intact, was actually being discharged for being combative, a reason not accurately reflected in the notice. Facility staff interviews revealed inconsistencies, including the lack of a physician's signature and the resident's care plan indicating he should remain in the facility.
Failure to Provide Ordered Antiretroviral Medication Due to Cost and Availability Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered antiretroviral medication to an immunocompromised resident in accordance with physician orders and the resident’s needs. The resident was admitted and readmitted with diagnoses including an immunocompromised disease, Type 2 diabetes mellitus with hyperglycemia, and major depressive disorder. The Medication Administration Records (MARs) showed an order for Biktarvy 50-200-25 mg once daily starting in October 2025. In October, the MAR reflected code “9” (other/see progress notes) on two days, but the corresponding progress notes were requested and not provided. In November, the MAR documented that Biktarvy was not administered on six separate days, again marked with code “9,” with associated order administration notes indicating the medication was not available. Progress notes for November documented multiple days when the antiretroviral medication was not given because it was not available at the facility. Nursing staff documented that the resident reported the medication had been ordered and they were waiting for it to arrive, that they were awaiting the resident to bring it from home, and that the resident had been out of the medication due to insurance changes and needed to call the pharmacy for a refill. Additional entries stated the facility was awaiting the resident to bring the medication from home, that the MD was aware, and that delivery was pending per the resident. During this period, the resident reported having had issues with insurance in the past that caused delays and missed doses of his medication. In interviews, multiple staff members, including LPNs, an RN, the interim DON, and the NHA, stated that the facility did not provide the resident’s Biktarvy because of its high cost and that the resident was responsible for supplying it. One LPN stated the resident went two days in a row without receiving Biktarvy and that the physician told her to put the medication on hold at that time, while also stating that Biktarvy and cancer medications were not provided by the facility due to cost. Another LPN and the RN confirmed that the medication was not available most of the time and that the facility did not pay for it. The interim DON reported that, upon admission, the resident was told he was responsible for the medication because it was too expensive for the facility, and did not confirm that any assistance was provided to help him obtain it. The NHA described a process in which high-cost medications are reviewed for possible alternatives and stated the prior DON decided not to approve this medication. The resident’s physician stated he had been informed the resident did not receive the medication for a week and a couple of days and that he told the facility they had to ensure the resident received it, emphasizing that it was a medication the resident could not go without and had to take every day. The facility reported having no policy for providing antiretroviral medications.
Failure to Document and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were properly documented and resolved over a five-month period. Review of Resident Council meeting minutes from June through October 2025 showed repeated discussions and requests from residents for more frequent provision of ice water and snacks. Despite these ongoing concerns, there was no documentation in the facility's grievance log reflecting these group issues, nor evidence that the concerns were formally tracked or followed up on as grievances. Interviews with two cognitively intact residents confirmed that the issues of hydration and snacks were discussed multiple times in Resident Council meetings, but no changes were observed in response to their requests. One resident reported that water refills were inconsistently provided, and another stated she had to get up at night to find water due to lack of refills. The Activities Director acknowledged that group concerns from Resident Council meetings were not entered as grievances, but rather discussed informally in Interdisciplinary Team (IDT) meetings without formal tracking or follow-up. She confirmed that if such concerns were entered as grievances, they would be tracked. The Nursing Home Administrator stated that grievances could be submitted by anyone and were logged and tracked by social services, but was unaware that Resident Council concerns were not being entered as grievances. Review of the facility's grievance policy indicated that all complaints or grievances should be documented, acted upon, and tracked, with prompt efforts made to resolve them. However, the facility did not follow its own policy regarding group concerns raised by the Resident Council, resulting in a lack of documentation and resolution for these grievances.
Failure to Provide Correct Beneficiary Notifications
Penalty
Summary
The facility failed to provide the correct beneficiary notifications to three residents regarding changes in their skilled services and related coverage. Specifically, the facility did not issue the Notice of Medicare Non-coverage (NOMNC) to residents who were discharged, instead providing only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). This issue was identified during a review of the Beneficiary Notice-Residents discharged within the Last Six Months form, which included 20 residents, with three randomly selected for detailed review. The residents involved were either discharged to an assisted living facility or home, and the NOMNC was not provided as required. The Social Services Director (SSD) revealed during an interview that the facility ceased issuing NOMNC forms as of a directive from the Administrator on October 31, 2024. The SSD was instructed to use a new SNF ABN form for all changes in skilled services, which led to the omission of the NOMNC for residents being discharged. The SSD acknowledged the mistake and noted that the residents were discharged from the facility, necessitating the provision of the NOMNC. The SSD also mentioned the need to treat the long-term care facility and the adjoining assisted living facility as separate entities, which was not done in this case.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their documented care needs and diagnoses. Resident #80's MDS did not reflect a diagnosis of Non-Alzheimer's Dementia, despite medical records and physician orders indicating its presence. This oversight was acknowledged by the MDS Registered Nurse as an error. Similarly, Resident #91's MDS failed to mark the use of antipsychotic and antianxiety medications, which were prescribed and documented in the resident's physician orders. This omission was also attributed to oversight by the MDS RN. Resident #56's MDS inaccurately documented the level of assistance required for transfers, stating partial/moderate assistance when the resident actually required a mechanical lift with maximum assistance, as confirmed by the Director of Rehab. Additionally, Resident #39's MDS inaccurately reported adequate vision, despite an eye doctor's note indicating highly impaired vision and cataracts. The resident's care plan lacked interventions for vision loss, and the resident expressed difficulty in identifying meals due to her vision impairment. The Director of Nursing confirmed the expectation for accurate MDS assessments, highlighting the facility's failure to meet this standard.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the accurate completion of Level I Preadmission Screening and Resident Review (PASRR) for nine residents out of a sample of 22. The deficiencies were identified through a review of admission records and interviews, revealing that several mental health and intellectual disability diagnoses were not marked on the PASRR forms. For instance, Resident #44's PASRR did not indicate major depressive disorder or muscular dystrophy, and Resident #55's PASRR omitted depressive disorder and epilepsy. Similar omissions were found in the PASRR forms of other residents, including those with diagnoses of bipolar disorder, schizophrenia, anxiety disorder, and conversion disorder with seizures. The Director of Nursing (DON) acknowledged the inaccuracies in the PASRR forms during an interview, stating that she was responsible for reviewing and ensuring the accuracy of these forms upon a resident's admission. The DON confirmed that the PASRRs for residents #5, #33, #39, #44, #55, #56, #91, and #94 were incorrect. The facility's policy requires that all admissions have the appropriate PASRR completed, and the DON is expected to update the PASRR if a resident receives a new diagnosis. The facility's policy outlines that the Center Administrator should designate either the Admissions Director or Social Worker to ensure the PASRR is completed for all potential residents. The policy also states that if a referral indicates a severe mental illness or intellectual disability, the PASRR must be completed before admission. However, the facility failed to adhere to these guidelines, resulting in incomplete and inaccurate PASRR documentation for multiple residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in addressing their specific needs. Resident #104 was admitted with a diagnosis of tobacco use, but the care plan did not include any interventions related to this condition. Similarly, Resident #4 and Resident #56, both with significant mobility issues, were inaccurately assessed as requiring only partial assistance for transfers, despite staff interviews indicating the need for a mechanical lift and maximum assistance. Resident #39, who was admitted with protein-calorie malnutrition and had highly impaired vision, did not have a care plan addressing her vision loss. This oversight resulted in her being unable to identify her meals, as staff did not inform her of the contents on her tray. Additionally, Resident #6, who was readmitted with multiple diagnoses and was receiving hospice care, lacked a care plan that included hospice services, despite ongoing eligibility and discussions by the hospice interdisciplinary group. Interviews with facility staff, including a CNA, the Director of Rehabilitation, and the MDS RN, confirmed the absence of appropriate care plans for these residents. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented within specific timeframes, yet these were not adhered to, resulting in unmet needs for the residents involved.
Care Plan Deficiencies for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were revised for five residents, leading to deficiencies in their care. Resident #13, who was admitted with dementia, chronic cough, and dysphagia, had a care plan that did not reflect the current dining assistance needs as indicated by the Director of Nursing's list. The care plan inaccurately described the resident as a feeder, despite the need for cueing and assistance during meals. Resident #10, diagnosed with dementia and gastro-esophageal reflux disease, had a care plan that was not updated to reflect the need for assistance with eating, as confirmed by a hospice aide. The care plan only mentioned set-up assistance, failing to address the resident's current requirement for cueing during meals. Similarly, Resident #6, with a diagnosis of senile degeneration of the brain and delusional disorders, had a care plan that lacked documentation of a skin impairment, despite having an active treatment order for an open area on the coccyx. Resident #65, with mood disorder and delusional disorder, exhibited verbally aggressive behavior, but the care plan had not been revised with alternate interventions since the previous year. This lack of update persisted despite ongoing incidents of aggression. Lastly, Resident #89, with a history of picking at his skin, had a care plan that did not include interventions for this behavior, as confirmed by staff interviews. The facility's policy requires care plans to be updated with changes in residents' conditions, but this was not adhered to, resulting in deficiencies in care planning and implementation.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice, affecting multiple residents. Three residents were not assisted with eating as per their care plans. One resident with contracted hands was observed struggling to feed himself without the necessary adaptive equipment, such as a sippy cup, and was left unattended during meals. Another resident required cueing and assistance with eating but was left alone with her meal tray, resulting in difficulty consuming her food. A third resident, who was visually impaired, was not informed about the contents of her meals, leading to confusion and difficulty in eating. Two residents were not properly assessed for transfers and were not provided with necessary equipment like wheelchairs. One resident expressed a desire to get out of bed but was unable to do so due to the lack of a wheelchair and the discomfort caused by a mechanical lift. Another resident had her wheelchair taken for another resident's use and had been waiting for a replacement for a year, leaving her confined to bed. Both residents were not reassessed for their transfer needs during their quarterly reviews, and their care plans did not reflect their actual assistance requirements. The facility also failed to appropriately notify a change in condition for a resident who experienced an alleged abuse incident. The resident's family and primary care provider were not informed until the day after the incident, delaying necessary medical intervention. Additionally, a resident with a fracture was not adequately assessed for pain, resulting in delayed pain management. The resident reported significant discomfort and inadequate pain relief, which was only addressed after repeated complaints. Furthermore, wound care was not consistently provided for two residents, with missed dressing changes and lack of proper documentation, leading to untreated and uncovered wounds.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for four residents, leading to dissatisfaction and unmet dietary needs. Resident #309 expressed frustration over not receiving hot tea, despite repeatedly requesting it since admission. The Food Service Director (FSD) acknowledged that a food preference sheet was not completed for this resident, which should have included hot tea as an option. The FSD admitted that any staff member could have fulfilled the resident's request, but it was not done. Resident #28, who has only three teeth, was unable to consume the chicken and asparagus provided on his lunch tray due to difficulty chewing. The resident stated that softer or ground food would be more suitable, but this need was not communicated to the staff. Staff U, an LPN assigned to the resident, was unaware of the resident's dental issues and the need for modified food textures. Resident #39, who is cognitively intact and has a diagnosis of protein-calorie malnutrition, reported not receiving her preferred breakfast items, such as yogurt and fruit, despite these preferences being documented. Additionally, Resident #71 noted the absence of condiments on meal trays, which the FSD confirmed should have been provided. The facility's policy on resident food preferences was not effectively implemented, resulting in unmet dietary needs and preferences for these residents.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service in the second-floor dining room. Observations revealed that residents at the same table were not served their meals simultaneously, leading to significant delays for some residents. For instance, at one table, a resident was served at 12:25 p.m., while their tablemate did not receive their meal until 12:44 p.m. Similar delays were observed at other tables, with some residents waiting up to 21 minutes after their tablemates had been served. This resulted in residents having to watch others eat while they waited for their meals, which is contrary to the facility's policy on dignity and respect. Interviews with staff, including CNAs and the Food Service Director, highlighted systemic issues contributing to the delays. Trays were delivered in room number order, and staff had to leave the dining room to deliver trays to residents' rooms, causing further delays in serving those dining in the room. The Food Service Director was unaware of the number of residents dining in the room, and the Director of Nursing stated that the expectation was for residents to be served simultaneously. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Honor Advance Directives for Two Residents
Penalty
Summary
The facility failed to honor the rights of two residents to formulate advance directives, leading to significant deficiencies in their care. Resident #259, who has a genetic-related intellectual disability and requires a surrogate for decision-making, was admitted to the facility with guardianship paperwork indicating that they lacked the capacity to make decisions. Despite this, the facility had the resident sign various documents, including vaccination consents and discharge paperwork, in violation of the court order. The guardian had informed the facility of the guardianship status, but the facility failed to act on this information appropriately. Resident #94, diagnosed with adult failure to thrive and schizophrenia, was also affected by the facility's failure to properly manage advance directives. The resident's admission records indicated the need for a surrogate, yet the facility incorrectly listed the resident as their own responsible party. Staff interviews revealed confusion and discrepancies in the resident's profile, with staff members acknowledging the mistake but failing to correct it. The resident's cognitive impairments were evident, yet the facility did not ensure that a surrogate was appointed to make decisions on their behalf. The facility's policies on resident rights and advance directives were not followed, leading to these deficiencies. Staff interviews highlighted a lack of communication and oversight in the admission process, with errors in documenting and verifying residents' decision-making capacities. The facility's failure to adhere to its own policies and procedures resulted in the violation of residents' rights to have their advance directives honored, as required by federal and state laws.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to ensure the privacy of residents' personal health information on the East unit. Multiple observations were made where medication carts were left unattended with computer screens unlocked, displaying residents' medical records. These incidents occurred in areas where residents and other individuals were present, such as hallways and near the nurses' station. Additionally, a lab book with a resident's face sheet was left visible on the top counter at the nurses' station, accessible to anyone passing by. Interviews with staff, including CNAs and an LPN, revealed that they were aware of the requirement to lock computer screens and secure papers containing resident information. The Director of Nursing confirmed that staff should lock computer screens and ensure that papers with resident information are not left on top counters. The facility's policy on resident rights prohibits unauthorized access or disclosure of resident information, emphasizing the need for compliance with privacy laws.
Failure to Prevent Pressure Ulcers in Resident with Fractures
Penalty
Summary
The facility failed to prevent the development of pressure wounds for a resident who was admitted with multiple fractures and other medical conditions. The resident, who had been involved in a car accident, was observed with several new open wounds on his right leg and buttocks. These wounds developed while the resident was in the facility, and the family member noted that the wounds were related to the brace the resident wore after the accident. However, the resident no longer wore the brace while in bed, and there were inconsistencies in the use of soft boots intended to prevent pressure ulcers. Observations and interviews revealed that the resident's wound care was not consistently managed. A dressing on the resident's leg was observed to have dried drainage and was not changed daily as required. The resident was not placed on an air mattress, which was recommended for pressure ulcer prevention, and there was confusion regarding the use of a pressure-reducing cushion in the resident's wheelchair. The nursing staff, including the wound nurse, acknowledged the challenges posed by the resident's immobilizers and the need for regular skin assessments, which were not consistently performed. The facility's policy on pressure ulcer prevention and management was not adequately followed. The resident's treatment records showed multiple orders for wound care and pressure ulcer prevention, but these were not effectively implemented. The resident's wounds were documented as in-house acquired, indicating a failure in the facility's preventive measures. The Director of Nursing and the wound nurse both recognized the deficiencies in care, including the lack of an air mattress and the need for more frequent dressing changes and skin assessments.
Deficiency in Safe Environment Due to Smoking Materials and Sharp Objects
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to smoking materials for one resident and the presence of razors and scissors in two resident rooms. Resident #104 was observed with smoking materials in his room, which were later removed without his knowledge. The resident was unaware of the facility's smoking policy, despite having signed an agreement upon admission. The staff responsible for the smoking area was not informed of the resident's possession of smoking paraphernalia, and there was no smoking evaluation or care plan related to smoking documented in the resident's medical record. Additionally, the facility did not maintain a safe environment concerning the storage of razors and scissors. Observations revealed that a pair of scissors and razors were stored in the bathrooms of two resident rooms. Interviews with staff indicated inconsistencies in the understanding and implementation of the facility's policy regarding the storage and supervision of razors and scissors. Some staff members believed razors should be stored in a locked supply room and provided to residents only under supervision, while others stated that male residents received razors in their welcome hygiene baskets. The Director of Nursing and the Administrator acknowledged the lack of a formal policy or procedure regarding the prohibition of razors and scissors in resident rooms. The facility's approach relied on staff education and assumed knowledge, which led to the presence of these potential hazards in resident rooms. This lack of clear policy and consistent implementation contributed to the deficiency in maintaining a safe environment for residents.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper post-dialysis communication and documentation for a resident with end-stage renal disease who required dialysis services. The resident's medical records from late January to late February 2025 lacked documentation of post-dialysis assessments or vital signs upon return to the facility. Additionally, there were no orders addressing the resident's central line access for dialysis or documentation of post-dialysis assessments. Interviews with nursing staff revealed that while there is an option to document post-dialysis assessments in the medical record, it was not being utilized by the facility. The Director of Nursing was unaware of this documentation option and acknowledged the absence of a section for post-dialysis assessment on the current dialysis communication sheet. The facility's policy on the care of AV-fistula-grafts outlines the need to check for signs of infection and bleeding at the cannulation site after dialysis. However, the lack of documentation and communication regarding post-dialysis assessments indicates a failure to adhere to these procedures. Nursing staff stated that they assess the dialysis site and vital signs upon a resident's return from dialysis, but this information was not being recorded in the medical records. This oversight in documentation and communication could potentially impact the quality of care provided to residents requiring dialysis services.
Failure to Complete Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were completed for two residents, leading to deficiencies in medication management. Resident #57 was admitted with a diagnosis of atherosclerotic heart disease and had physician orders for Peridex mouth/throat solution. The Consultant Pharmacist recommended that the order be clarified to instruct the resident to swish and not swallow the solution. However, these recommendations were not completed or signed by the physician. The Consultant Pharmacist noted that there had been ongoing issues with the facility not completing pharmacy recommendations. Resident #5, who was admitted with multiple diagnoses including brief psychotic disorder and moderate major depressive disorder, also had unaddressed pharmacy recommendations. The Consultant Pharmacist suggested specific dosing instructions for Diclofenac gel and changes to the orders for Midodrine and Calcitonin Nasal solution. These recommendations were not incorporated into the resident's physician orders. The Director of Nursing acknowledged receiving the recommendations but admitted to falling behind and missing them. Additionally, the facility lacked a policy for handling pharmacy recommendations, which contributed to the oversight.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications on both units, as observed during a survey. On multiple occasions, medication carts were found unlocked and unattended, with medications left on top of the carts. Specifically, on the second floor, two bottles of medication were left on top of an unattended cart, and on the first floor, a cart was found unlocked with no staff nearby. Additionally, a nurse was observed leaving a cart unlocked after retrieving an item. Medications were also found unsecured in resident rooms, including over-the-counter medications in an open bedside drawer and medication cups left on overbed tables. Interviews with the Consultant Pharmacist and the Director of Nursing (DON) revealed that the facility's practices did not align with their policy on medication storage and labeling. The Consultant Pharmacist noted that he had also found an unlocked medication cart during his spot checks and emphasized the need for vigilance regarding medications brought in by families. The DON confirmed that all medication carts should be locked, and medications should not be left at residents' bedsides or in their rooms. The facility's policy requires medications to be stored in secured, locked locations accessible only to designated staff, which was not adhered to in these instances.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement protocols from its antibiotic stewardship program for a resident who was receiving intravenous antibiotics for a severe urinary tract infection (UTI). The resident, who had been readmitted to the facility with diagnoses including infection and inflammatory reaction due to a UTI and indwelling urethral catheter, was observed with two empty bags of Vancomycin at her bedside. The resident was unaware of the duration of her antibiotic treatment, indicating a lack of communication and documentation regarding her care plan. A review of the resident's physician orders revealed that there were no end dates specified for the antibiotics Vancomycin and Cefepime, which were prescribed for the UTI. The Director of Nursing (DON) acknowledged that all antibiotics should have an end date to ensure proper monitoring of antibiotic duration, as part of the facility's antibiotic stewardship program. The facility's policy on antibiotic stewardship, revised in December 2016, requires prescribers to provide complete antibiotic orders, including the duration of treatment. The absence of an end date for the antibiotics in this case was identified as a problem by the DON.
Inaccurate Discharge Notice Issued to Resident
Penalty
Summary
The facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice. The notice provided to the resident cited non-payment and improved health as reasons for discharge, despite the resident not owing any money to the facility and his health not having improved sufficiently for discharge. The resident, who was cognitively intact with a BIMS score of 15, was informed of the discharge due to being combative, a reason not accurately reflected in the notice. Interviews with facility staff, including the Nursing Home Administrator, Business Office Manager, Social Worker, and Director of Nursing, revealed inconsistencies and inaccuracies in the discharge notice. The Social Worker admitted to not knowing the financial details of the resident's account and acknowledged that the physician's signature on the notice was not obtained. The Director of Nursing confirmed the resident's need for nursing care and that his health had not improved enough for discharge, contradicting the reasons stated in the notice. The comprehensive care plan indicated the resident's discharge plan was to remain in the facility, further highlighting the discrepancy in the discharge notice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sebring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Sebring | 0.5 mi | ★★★★★ | 1 | 0 |
| Oaks At Avon | 8.8 mi | ★★★★★ | 1 | 0 |
| Royal Care Of Avon Park | 10.5 mi | ★★★★★ | 1 | 0 |
| Lake Placid Health And Rehabilitation Center | 12.6 mi | ★★★★★ | 2 | 0 |
| Vivo Healthcare Wauchula | 22.8 mi | ★★★★★ | 0 | 0 |
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