Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plaza Health And Rehab during CMS and state inspections, most recent first.
A resident admitted with a PICC line for IV antibiotics did not have physician orders or documentation for required PICC dressing changes. The LPN Unit Manager confirmed that orders for dressing changes should be entered and documented, but this was not done. Facility policy requires weekly sterile dressing changes with documentation, which was not followed in this case.
The facility did not update PASRR assessments for two residents who were newly diagnosed with serious mental health conditions, including bipolar disorder, major depressive disorder, and schizophrenia. The PASRR forms on file did not reflect these diagnoses, and staff confirmed that updates were not made as required by facility policy.
A resident with orthostatic hypotension and brittle diabetes did not consistently receive Midodrine and Novolog insulin as ordered, with multiple instances of missing documentation, failure to follow medication parameters, and lack of physician notification or progress notes when medications were held or administered outside of prescribed guidelines.
Three chipped serving trays with jagged edges were observed in use during meal service, and the Food Services Director acknowledged that such trays could cause injury to residents with fragile skin. Despite this, the trays were distributed to residents' rooms, resulting in food not being served in a safe manner for several residents.
A resident's discharge status was inaccurately recorded in the MDS as a transfer to a hospital instead of a discharge home with home health care. The error was confirmed by the MDS Coordinator and the DON, who acknowledged the misclassification.
A resident with a midline IV line did not receive appropriate dressing changes and site assessments according to facility policy. The gauze under the transparent dressing was not removed, obstructing the view of the IV insertion site, and the dressing was loose. Staff interviews confirmed non-compliance with the policy requiring dressing changes 24 hours post-insertion. The facility's policy emphasized the need for sterile dressing changes to prevent infection, which was not adhered to in this instance.
The facility failed to properly store, label, and maintain food items in the kitchen, with issues such as ice buildup in the freezer, unlabeled food items, and improper storage of raw chicken. Additionally, kitchen equipment was not maintained, with an ice machine showing contamination and a sink overflowing. The Registered Dietician confirmed these deficiencies, which were not in line with the facility's policies.
The facility failed to maintain complete medical records for two residents regarding lab result reporting. One resident's lab results showed significant growth of Providencia stuartii, but there was no documentation of physician notification. Similarly, another resident's lab results indicated Escherichia coli growth, with no documented communication to the physician. The DON acknowledged the lack of documentation and the absence of a policy for such procedures.
Failure to Document and Order PICC Line Dressing Changes for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident who was receiving intravenous (IV) medication via a peripherally inserted central catheter (PICC) line. Upon admission, the resident had a PICC line in place and was receiving IV antibiotics as ordered by the physician. The care plan identified the resident as being at risk for complications related to IV therapy and included interventions such as administering IV medications as ordered, performing IV flushes, changing IV tubing per protocol, and performing IV site care as ordered. However, a review of the resident's physician orders revealed there were no orders for PICC line dressing changes, and the medication and treatment administration records for the relevant months showed no documentation that PICC dressing changes were completed. During an interview, the LPN Unit Manager confirmed that when residents are admitted with a PICC line, it is necessary to select and enter orders for dressing changes, flushes, and monitoring for infection. The LPN stated that if there is no order for a PICC dressing change, nurses are expected to enter the order and document the dressing change. The facility's policy requires sterile dressing changes for PICC lines at least weekly, with documentation in the clinical record. The absence of both physician orders and documentation for PICC dressing changes indicated a failure to maintain complete and accurate records in accordance with professional standards.
Failure to Update PASRR Assessments for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for residents with newly diagnosed mental disorders. For one resident, the admission record and care plan notes documented new diagnoses of post-traumatic stress disorder, anxiety disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder. However, the PASRR form on file only listed dementia as a secondary diagnosis and did not reflect the new mental health diagnoses. There was no updated PASRR completed to account for these changes, despite facility policy requiring updates when significant changes in a resident's status occur. Another resident was admitted with a diagnosis of paranoid schizophrenia, but the PASRR form only documented anxiety and depressive disorders, omitting the psychotic disorder and schizophrenia diagnoses. Interviews with facility staff confirmed that the PASRR forms were not updated to reflect the residents' current mental health conditions. The facility's policy states that residents with mental disorders should be screened and that updates should be made when significant changes occur, but this was not followed in these cases.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically regarding the administration of Midodrine HCl and Novolog FlexPen insulin. The physician's order for Midodrine HCl required the medication to be held if the resident's systolic blood pressure (SBP) exceeded 130. However, medication administration records (MARs) showed instances where the medication was administered when the SBP was above the ordered parameter, and there were also occasions where documentation of blood pressure and nursing notes were missing when the medication was held or administered. Additionally, there were no progress notes explaining the rationale for holding or administering the medication outside of parameters, nor was there evidence of physician notification as required by the order and facility policy. For Novolog FlexPen insulin, the resident had orders for both scheduled doses and sliding scale administration. The MARs revealed multiple instances where insulin doses were held, omitted, or not documented, and in several cases, there were no corresponding progress notes or documentation of physician notification. Blood sugar readings were sometimes recorded as low or within a range that would typically require physician notification, but there was no evidence in the medical record that the physician was contacted or that a clinical decision was documented. Staff interviews confirmed that the expectation was to notify the physician and document actions taken when insulin was held due to low blood sugar, but this was not consistently done. The resident involved had a history of orthostatic hypotension and brittle diabetes mellitus, requiring careful monitoring and adherence to medication parameters. The lack of documentation, failure to follow physician orders, and absence of communication with the physician regarding medication administration and blood sugar results contributed to the deficiency. The facility's own policy required timely administration of medications as prescribed and appropriate documentation, which was not followed in these instances.
Unsafe Food Tray Use During Meal Service
Penalty
Summary
During a kitchen tour, three black serving trays with chipped, jagged edges were observed in the dish cleaning area. The Food Services Director confirmed that trays with jagged edges could cause bleeding to residents with fragile skin and acknowledged that such trays should not be used. Later, during dinner service, three food trays with chips and jagged edges were observed being distributed to residents' rooms in the F Villa. Photographic evidence was obtained of the trays in use. These observations indicate that food was not served in a safe manner for three of twelve residents observed during meal service.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, specifically for one resident reviewed for discharge. The deficiency involved a misclassification of the discharge status for a resident who was supposed to be discharged home with home health care. The physician's order and the Nursing Home Transfer and Discharge Notice indicated that the resident would be discharged home. However, the Minimum Data Set (MDS) inaccurately recorded the discharge status as a transfer to a short-term general hospital. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the discharge status was incorrectly coded, acknowledging it as an error.
Failure to Change PICC Line Dressing and Assess IV Site
Penalty
Summary
The facility failed to adhere to professional standards of practice for changing a PICC line dressing and assessing an IV site for a resident with a midline IV. The resident, admitted with acute bronchitis, cellulitis, sepsis, and pneumonia, had a midline IV line in the right arm. During an observation, it was noted that the gauze under the transparent dressing was not removed, obstructing the view of the IV insertion site, which had a small amount of dried red residue. The dressing was also loose, compromising its integrity. The facility's policy required the dressing to be changed and the gauze removed 24 hours post-insertion, but this was not done, as evidenced by the lack of documentation for dressing changes on the Medication Administration Record (MAR) for several days. Interviews with staff revealed a lack of compliance with the facility's policy. Staff A, an LPN, and the Unit Manager, confirmed that the gauze should have been removed after 24 hours to allow proper assessment of the IV site. Staff C, another LPN, and Staff B, an RN, acknowledged the inability to assess the site due to the gauze and the loose dressing. The Director of Nursing reiterated the policy requirement for dressing changes and the removal of gauze to prevent infection. The facility's policy, last reviewed in January 2024, emphasized the need for sterile dressing changes 24 hours post-insertion and when the dressing's integrity is compromised, which was not followed in this case.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper storage, labeling, and sanitation of food items in the kitchen, specifically in the walk-in cooler and freezer. During an initial observation, a large amount of ice buildup was noted on the door and walls of the walk-in freezer, affecting two boxes of food. A pan of red gelatin was found with a serving scoop left inside and without an identifying label or date. In the walk-in cooler, several items, including a large pot of liquid, almond milk, pasta, raw ground beef, and a pan of lettuce, tomatoes, and cheese, were improperly labeled or not labeled at all. Raw chicken was stored on top of ready-to-serve garlic toast, and two 5-gallon containers were stored on the floor. Additionally, dirty gloves were found in the sanitizing sink, indicating a lack of adherence to sanitary standards. Further observations revealed additional issues with kitchen equipment. The ice machine had a black/gray substance around its opening, and a 3-door reach-in cooler and a convection oven were marked with signs indicating they were not to be used, but lacked proper lockout/tagout procedures. The 3-compartment sink was overflowing, with water spilling onto the kitchen floor. Interviews with the Registered Dietician (RD) confirmed these observations, and the RD was unable to explain the equipment malfunctions or the presence of the black/gray substance. The facility's policies on refrigerated storage and ice machine cleaning were not followed, contributing to these deficiencies.
Incomplete Documentation of Lab Results for Two Residents
Penalty
Summary
The facility failed to maintain complete medical records for two residents regarding laboratory result reporting. Resident #34 was admitted with multiple diagnoses, including multiple sclerosis, chronic kidney disease, and dementia. A physician ordered a urinalysis with culture and sensitivity for the resident, and the lab results indicated a significant growth of Providencia stuartii. However, there were no nursing progress notes documenting the physician's notification of these results. The Director of Nursing (DON) admitted to notifying the physician verbally but failed to document the communication, acknowledging the oversight. Similarly, Resident #128, who had diagnoses including hemiplegia, diabetes, and urinary tract infection, had a physician order for a urinalysis with culture and sensitivity. The lab results showed a significant growth of Escherichia coli, but again, there was no documentation in the nursing progress notes regarding physician notification. The DON stated that the physician was aware of the results, but the nurse did not document the communication. The DON also noted the absence of a policy and procedure for documentation, which contributed to the lack of proper record-keeping.
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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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Meadows Healthcare & Rehabilitation Center | 1.5 mi | ★★★★★ | 30 | 0 |
| Gainesville Health And Rehabilitation | 1.6 mi | ★★★★★ | 4 | 0 |
| Oak Hammock At The University Of Florida Inc | 2.3 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Gainesville | 2.3 mi | ★★★★★ | 0 | 0 |
| Terrace Healthcare & Rehabilitation Center | 3.3 mi | ★★★★★ | 7 | 0 |
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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.