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 Royal Care Of Avon Park during CMS and state inspections, most recent first.
Two residents with known behavioral conflict and one with dementia and mood instability engaged in a verbal altercation in a common area that escalated when one resident kicked the other, causing a fall and shoulder injury, while no staff were present to intervene. Staff had prior knowledge of the aggressive resident’s history of verbal and physical behaviors and the pair’s past roommate conflicts, and behavior monitoring for psychotropic use lacked specific behavior descriptions. The DON later confirmed that key staff statements were not obtained and that staff could not clearly describe the behaviors previously documented, demonstrating a failure to provide adequate supervision and behavior-specific monitoring to prevent resident-to-resident abuse.
A resident developed a Stage 4 pressure ulcer due to the facility's failure to identify and treat a new area of skin impairment. The resident did not receive adequate preventive measures or timely treatment, resulting in an infected ulcer that required hospitalization and a wound vac.
The facility failed to maintain a clean and homelike environment, with surveyors detecting offensive odors in the front lobby, nurses' station, and four resident rooms over several days. The Environmental Services Director acknowledged that their audit process does not include checking for odors, and despite using an IT ticket system for reporting concerns, the issue persisted.
The facility failed to ensure accurate PASARR screenings for multiple residents, missing key diagnoses that could have warranted Level II reviews. Interviews revealed that the process for reviewing and correcting PASARRs was not adequately followed.
The facility failed to provide proper wound care for four residents and did not obtain physician's orders for hand splints for one resident. Observations revealed undated and soiled dressings, improper sterile techniques, and lack of documentation for wound care and refusals, leading to deficiencies in care.
The facility failed to ensure proper storage of drugs and biologicals, with treatment carts left unlocked and a bottle of nasal spray found on a resident's bedside dresser. Staff acknowledged the oversights and secured the carts after being made aware.
The facility failed to maintain food safety standards, including unclean kitchen areas, improper food storage, and inadequate equipment maintenance. Black soil was found on the floors of the walk-in refrigerator and freezer, expired egg salad was stored, and a black substance resembling biogrowth was noted on a wall. Additionally, frozen ground beef was improperly thawed, and a spatula with burnt edges and broken thermometer were found. These deficiencies were confirmed by the facility's dietitian and dietary director.
The facility failed to maintain an effective infection control program, with staff not donning appropriate PPE, not assisting residents with hand hygiene before meals, and not maintaining urinary catheters in a sanitary manner. Additionally, inconsistencies in cleaning medical equipment were observed.
The facility failed to securely affix handrails in the corridors of the West and South units. During tours, multiple handrails were found to be loose and not firmly secured to the wall. Staff and the Director of Environmental Services acknowledged the issue, but discrepancies were found in the inspection process.
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations revealed that staff did not remove dinnerware from trays when serving residents, and plate covers remained on the tables while residents dined. Interviews indicated a lack of awareness or adherence to the facility's policy on dignity.
A resident with broken, chipped teeth and dental caries was inaccurately documented as having normal dentition in multiple assessments. Despite visible dental issues, no care plan or dental consults were provided, and the resident's medical records consistently marked her dental status as normal.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive proper IV medication administration. The IV tubing was not labeled, and a significant amount of vancomycin remained in the bag. Staff could not explain the oversight, and the DON confirmed it was a medication error.
The facility failed to ensure proper respiratory care for residents, including improper storage of equipment, lack of physician's orders, failure to change oxygen tubing weekly, and missing cautionary signage. Staff interviews and observations confirmed these deficiencies.
The facility failed to post complete daily nursing staff information. Observations on 5/9/24 revealed missing details for the 7 p.m. to 7 a.m. shift and the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. A review of the 5/8/24 posting also showed missing CNA and PCA information for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts.
The facility failed to administer antihypertensive medications according to prescribed parameters for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and essential hypertension. The medications Losartan, Diltiazem, and Spironolactone were given outside of the specified blood pressure limits, as confirmed by the DON.
The facility failed to maintain a medication error rate below 5%, resulting in a 21.43% error rate. An RN crushed extended-release medications and administered them incorrectly to a resident, and administered medications late to another resident. The DON confirmed the errors and policy violations.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive the full dose of prescribed vancomycin intravenously. The IV tubing was not labeled, and a significant amount of medication remained in the bag. Staff and the DON confirmed this as a medication error, and the facility's policy was not followed.
A resident with several broken, chipped teeth, and dental caries was not assisted in obtaining routine dental care. Despite being cognitively intact and having obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the dental status. Interviews revealed that the facility's protocol for dental referrals was not followed, leading to the deficiency.
Failure to Supervise Leading to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident abuse, resulting in a physical altercation between two residents. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including abnormalities of gait and mobility, muscle weakness, and type 2 diabetes, alleged that another resident kicked her, causing a fall and subsequent left shoulder pain. Resident #3, who had severe cognitive impairment with a BIMS score of 6 and diagnoses including unspecified mood disorder, depression, and dementia, had a documented history of verbally and physically threatening staff and other residents, aggressive behavior, and pilfering items. The facility’s care plan for Resident #3 identified behavioral symptoms and cognitive loss/dementia, with approaches including redirection, diversional activities, and, later, 1:1 sitter supervision. Prior to the incident, staff were aware that Resident #3 exhibited verbal aggression and had prior altercations with other residents to the point of needing separation, and that the two involved residents had previously been roommates who did not get along, leading to a room change. Resident #3 was also on Depakote for mood instability, mood swings, and aggression, with behavior monitoring ordered. However, the behavior monitoring documentation for January showed only intervention codes (e.g., giving food, fluids, encouraging rest) without any description of the specific behaviors exhibited, and facility staff, including the MDS coordinators, could not state what behaviors had occurred on those dates despite acknowledging that some type of behavior must have been present. The facility’s abuse policy required identification of residents with behaviors that might lead to conflict, sufficient supervision, and monitoring for changes that could trigger abusive behavior, but the documentation and staff interviews did not demonstrate clear, behavior-specific monitoring or consistent preventive supervision. On the day of the event, the altercation occurred in the east wing atrium/common area near the nurses’ station. Resident #8, another resident, reported witnessing Resident #3 approach Resident #2 in a wheelchair, exchange derogatory names, stand up from their wheelchairs, and then kick Resident #2 in the shin, causing Resident #2 to fall to her left side. Resident #8 stated no staff were present at the time. Staff B, an RN, reported hearing Resident #2 crying and asking for help, then seeing her in her wheelchair and separating the residents, but did not witness the actual kick or fall. The DON’s investigation notes, based on interviews, indicated that Resident #3 admitted to pushing another resident after a verbal altercation, and that Resident #2 and Resident #8 both described Resident #3 kicking Resident #2 and causing her to fall. The facility’s abuse policy required sufficient staffing, supervision, and obtaining signed witness statements, but the DON confirmed that written, signed staff statements were not obtained from key staff present that shift, and staff could not clearly account for supervision at the time of the incident, supporting the finding that the facility failed to provide adequate supervision to prevent resident-to-resident abuse.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to identify and treat a new area of skin impairment for a resident, which resulted in the development of an advanced stage pressure ulcer. The resident, who had multiple health conditions including Type 2 Diabetes Mellitus, muscle weakness, and spinal stenosis, initially had no pressure ulcers upon admission. However, the resident developed an unstageable pressure ulcer on the sacral region, which later progressed to a Stage 4 pressure ulcer. The resident reported that the facility did not provide adequate treatment or preventive measures, such as a special mattress, until the ulcer had significantly worsened and become infected, necessitating hospitalization and the use of a wound vac for treatment. Observations and interviews revealed that the resident was often positioned on his back and did not receive consistent repositioning or the use of heel protectors as outlined in his care plan. The facility's documentation showed gaps in progress notes and skin assessments, with no records indicating the development of the pressure ulcer at a lower stage. The facility's Director of Nursing and Medical Director provided conflicting information about the resident's care and the timeline of the pressure ulcer's development. The Medical Director initially claimed the ulcer was unavoidable due to the resident's debility but later admitted to not being familiar with the resident's case. The facility's policy on pressure ulcer prevention and treatment was not adequately followed, as evidenced by the lack of timely assessments, appropriate interventions, and consistent documentation. The resident's care plan included measures such as turning and repositioning every two hours, using an air mattress, and reporting changes in skin condition to the primary care physician. However, these interventions were not consistently implemented, leading to the resident's pressure ulcer progressing to an advanced stage and causing significant harm.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment, as evidenced by the presence of offensive odors in multiple areas. Upon entering the facility, the survey team detected a smell of old urine in the front lobby. Similar odors were noted in front of the nurses' station and in four resident rooms over the course of several days. Specifically, rooms 103, 107, 109, and 110 were identified as having strong and offensive odors, some of which were not related to urine. These observations were made at various times, indicating a persistent issue with maintaining a clean environment. An interview with the Environmental Services Director revealed that the facility's current audit process does not include checking for offensive odors. The Director mentioned that if an odor is noticed, a deep clean is performed, and that room 110B had recently undergone such a cleaning, including a bed replacement. The facility uses an IT ticket system for reporting environmental concerns, which are then prioritized and addressed by the Environmental Services team. Despite these measures, the persistent odors suggest that the current processes are insufficient to maintain a consistently clean and homelike environment for residents.
Inaccurate PASARR Screenings for Multiple Residents
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents. Resident #15 was admitted with diagnoses including vascular dementia, bipolar disorder, and major depressive disorder, but the PASARR did not reflect these diagnoses, and no Level II PASARR was required. Similarly, Resident #26's PASARR did not include a diagnosis of bipolar disorder, and Resident #28's PASARR missed several qualifying diagnoses such as anxiety, schizoaffective disorder, and PTSD. These inaccuracies were not corrected at the time of admission, which could have warranted a Level II PASARR review. Additionally, Resident #38's PASARR was not updated to reflect a new diagnosis of schizoaffective disorder, which was added after the initial screening. This oversight meant that a Level II PASARR review was not conducted when it should have been. Interviews with the Director of Nursing and the Social Services Director revealed that the facility's process for reviewing and correcting PASARRs was not adequately followed, leading to these deficiencies.
Failure to Provide Proper Wound Care and Follow Physician's Orders
Penalty
Summary
The facility failed to provide wound care and treatment in accordance with professional standards of practice for four residents and did not ensure physician's orders were obtained for the application of splints for one resident. Resident #67 had a wound infection on his right knee that required dressing changes. However, the wound dressing was observed without a documented date, and the facility did not follow the physician's orders for wound care. Resident #328 had a wound on his right middle finger that was supposed to be dressed daily, but the dressing was not applied, and there was no documentation of the resident refusing treatment or removing the dressing himself. The facility's staff failed to document the wound care treatment and any refusals properly, as per the facility's policy. Resident #36 was observed with a soiled and undated dressing on his right shin, which was not changed as per the treatment administration record. The resident had a skin tear that required dressing changes every other day, but the facility did not follow the prescribed wound care protocol. Resident #177 had bilateral below-knee amputations with sutures/staples in the surgical sites. The wound dressing changes were not performed using proper sterile techniques, as the nurse used bare hands to handle gauze and did not clean the scissors between cutting the old and new dressings. This practice was against the facility's policy for dry/clean dressings. Resident #41 was observed wearing bilateral hand splints without a physician's order. The resident's care plan did not include the use of hand splints, and the occupational therapist confirmed that the splints were not part of the care plan. The facility's policy required that care plans be individualized and include all necessary interventions, but this was not done for Resident #41. The lack of proper documentation and adherence to physician's orders and facility policies led to deficiencies in the care provided to these residents.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by two specific incidents. On two separate days, a treatment cart was observed unlocked and unattended in the South unit hallway. On the first occasion, a Registered Nurse (RN) admitted to leaving the cart unlocked after receiving items from the pharmacy. On the second occasion, the facility's Infection Preventionist (IP) and Assistant Director of Nursing (ADON) did not notice the unlocked cart and walked away without securing it. Both instances were acknowledged by the staff involved, who subsequently locked the cart after being made aware of the oversight. Additionally, during a medication administration observation, a bottle of nasal spray was found on a resident's bedside dresser. The RN administering the medication was unaware of how the nasal spray got there and speculated it might have been placed by a family member. The Director of Nursing (DON) later confirmed that no residents were allowed to self-administer medications and that all medications should be stored in the facility's medication carts. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts be locked when not in use.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to maintain food safety standards, which included maintaining clean floors and walls, properly storing ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food, thawing frozen TCS food correctly, and keeping equipment in good condition. During an initial tour of the kitchen, black soil was observed on the floors of the walk-in refrigerator and freezer. A container of egg salad with an expired use-by date was found in the reach-in refrigerator, and a black substance resembling biogrowth was noted on a wall in the dry storage area. Additionally, a 10-pound log of frozen ground beef was improperly thawed in a prep sink without running water, and a spatula with burnt edges was found hanging above the sink. The same spatula was observed again during a follow-up visit, along with three scoops with rough, uncleanable plastic handles. A broken thermometer was also found in a resident nourishment mini refrigerator. These observations were confirmed through interviews with the facility's dietitian and dietary director, who provided documentation of previous training and performance improvement plans that did not address the identified concerns during the survey. The facility's policies on sanitization and food storage were not adhered to, as evidenced by the unclean kitchen areas and improper food handling practices. The kitchen weekly cleaning schedule indicated that specific staff members were responsible for cleaning the walk-in refrigerator, freezer, and storage room, but these tasks were not adequately performed. The facility's dietitian and dietary director acknowledged the deficiencies and provided documentation of employee training and performance improvement plans, but these measures were insufficient to prevent the identified issues. The failure to maintain food safety standards has the potential to cause foodborne illness for the majority of the facility's residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to develop and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Staff members did not don appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission-based precautions for COVID-19. Specifically, staff were observed entering rooms without eye protection, and some staff donned N95 masks over surgical masks, which compromised the fit and effectiveness of the N95 masks. Additionally, staff did not doff PPE before exiting the rooms, further risking the spread of infection. Interviews with staff revealed a lack of awareness and understanding of the proper PPE protocols, and the facility's Infection Preventionist and Director of Nursing confirmed that the observed practices were not in line with the facility's policies or infection control guidelines. The facility also failed to ensure proper hand hygiene practices for residents before meals. During meal service observations, residents were not assisted with hand hygiene, which is a critical step in preventing the spread of infections. This lapse in protocol was confirmed by the Director of Nursing during an interview. Additionally, the facility did not maintain urinary catheters in a sanitary manner. Observations showed catheter tubing lying on the floor, which poses a significant risk for infection. The care plan for the resident with the urinary catheter explicitly stated that the drainage bag should be kept below the waist and off the floor, but this was not adhered to. Further deficiencies were noted in the cleaning and disinfection of medical equipment. During a medication administration observation, a registered nurse did not clean the stethoscope used for blood pressure measurement, although other equipment was disinfected. This inconsistency in following infection control protocols highlights a broader issue within the facility's infection prevention and control program. The facility's policies, last revised in January 2021, were not being effectively implemented or followed by the staff, leading to multiple instances of non-compliance and increased risk of infection spread among residents and staff.
Failure to Securely Affix Handrails in Corridors
Penalty
Summary
The facility failed to equip corridors with securely affixed handrails on two of its three units, specifically the West and South units. During a tour on the [NAME] unit, a handrail between rooms was observed to be loose and not firmly secured to the wall. Similarly, on the South unit, multiple handrails between rooms were found to be loose and not securely affixed. Staff I, an LPN on the South unit, acknowledged the issue but admitted she had not noticed the loose handrails prior to the survey. The Director of Environmental Services (DES) also confirmed the handrails were loose and stated that inspections are conducted weekly, and maintenance concerns can be documented in the electronic maintenance system. However, the Weekly Hand Rail Checks for the [NAME] unit showed no issues, indicating a discrepancy in the inspection process. The facility's policy on maintenance service, last revised in December 2009, mandates that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. This includes maintaining the building in compliance with federal, state, and local laws, and ensuring the building is free from hazards. Despite this policy, the observations during the tours and the interviews with staff revealed that the handrails were not maintained in a safe condition, leading to the identified deficiency.
Failure to Maintain Dignity and Homelike Dining Experience
Penalty
Summary
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations on multiple occasions revealed that staff did not remove dinnerware from trays when serving residents. Specifically, during the noon meal service, several residents were served their meals with dinnerware left on the trays, and plate covers remained on the tables while residents dined. This practice was observed with four out of five residents sitting at the dining tables. Additionally, the Director of Nursing (DON) was seen standing over a resident and cutting up food with the dinnerware still on the serving tray. Interviews with staff, including the Assistant Director of Nursing/Risk Manager (ADON/RM) and the Dietary Director, indicated a lack of awareness or adherence to the facility's policy regarding the removal of dinnerware from trays. The DON confirmed that plates should be removed from trays, but the facility's policy was not readily available. The facility's policy on dignity, revised in August 2009, emphasized treating residents with dignity and respect, which includes assisting them in maintaining and enhancing their self-esteem and self-worth. However, the observed practices did not align with this policy, leading to the deficiency.
Inaccurate Dental Status Documentation
Penalty
Summary
The facility failed to accurately reflect a resident's dental status, as observed during multiple instances. Resident #17 was noted to have several broken, chipped teeth, dental caries, and black gums around several teeth. Despite these observations, the resident's Annual Minimum Data Set (MDS) assessments did not document any dental issues, and the resident did not have a care plan addressing her dental status. The resident's weight had gradually decreased over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical records, including social history assessments, speech therapy screens, and nutritional evaluations, consistently marked her dental status as normal, with no referrals necessary for dental issues. Progress notes from healthcare providers also documented normal dentition, with no indication of dental consults or services provided to the resident. The Director of Nursing was informed of the inaccuracies in the resident's MDSs regarding her oral/dental status.
Failure to Properly Administer IV Medication
Penalty
Summary
The facility failed to provide proper administration of intravenous (IV) medication in accordance with professional standards of practice for a resident diagnosed with Parkinson's Disease and an infection due to an internal left knee prosthesis. The resident had a physician's order for vancomycin to be administered intravenously every other day. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag, indicating that the medication was not fully administered. Staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), were unable to explain why the IV tubing was not labeled or why the medication was not fully administered. Further interviews with the Unit Manager (UM) and the Director of Nursing (DON) confirmed that the IV tubing and medication should have been labeled with the date and that the medication should have been fully administered. The DON stated that the medication should run via an IV pump or a manual flow regulator until fully administered and that failure to do so would be considered a medication error. Photographic evidence supported these findings, and the staff acknowledged the oversight but could not provide a reason for the lapse in proper procedure.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, specifically in the areas of equipment storage, obtaining physician's orders, changing oxygen tubing, and posting necessary signage. Resident #54 was observed with an oxygen concentrator and nasal cannula tubing that was not dated or stored in a plastic bag as required. Additionally, there was no physician's order for oxygen therapy for Resident #54 prior to 5/9/2024, despite the resident using oxygen on an as-needed basis. Interviews with staff confirmed that the equipment should have been labeled and stored properly, and a physician's order should have been in place before administering oxygen. Resident #126's oxygen tubing was not changed weekly as per physician's orders, with the tubing dated 4/21/24 still in use on 5/7/24. Furthermore, there were no cautionary and safety signs indicating the use of oxygen posted outside Resident #126's room. The resident's medical records and care plan indicated a need for oxygen therapy due to conditions such as COPD and recent respiratory failure. Interviews with staff and the DON confirmed that the oxygen tubing should be changed weekly and that appropriate signage should be posted. The facility's policies on oxygen administration and storage of respiratory equipment were not followed, leading to these deficiencies. The policies required a physician's order for oxygen administration, proper storage of respiratory equipment in plastic bags, and weekly changes of oxygen tubing. The lack of adherence to these policies was confirmed through staff interviews and observations, highlighting a failure to provide respiratory care in accordance with professional standards.
Incomplete Daily Nursing Staff Information
Penalty
Summary
The facility failed to post daily nursing staff information accurately, as required. On 5/9/24 at 8:13 a.m., the posted staffing information in the front lobby was observed to be incomplete. The posting, dated 5/9/24, indicated a census of 79 residents and listed the staffing for the 7 a.m. to 7 p.m. shift, including 3 Registered Nurses (RN) and 5 Licensed Practical Nurses (LPN), and for the 7 a.m. to 3 p.m. shift, including 9 Certified Nursing Assistants (CNA) and 1 Patient Care Assistant (PCA). However, it did not include the number of licensed staff scheduled for the 7 p.m. to 7 a.m. shift or the number of CNAs or PCAs scheduled for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts. Additionally, a review of the daily staffing information dated 5/8/24 showed no CNA or PCA information for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts.
Failure to Administer Antihypertensive Medications per Parameters
Penalty
Summary
The facility failed to provide medications appropriately for one resident out of five sampled, specifically related to antihypertensive medications. The resident, who had diagnoses including Type 2 Diabetes Mellitus with hyperglycemia, unspecified cirrhosis of the liver non-alcoholic, and essential hypertension, was administered Losartan, Diltiazem, and Spironolactone outside of the prescribed parameters. For instance, Losartan was given on two occasions despite the resident's systolic blood pressure being below the threshold. Similarly, Diltiazem was administered when the resident's blood pressure was below the set limit, and Spironolactone was inconsistently administered. The Director of Nursing confirmed that the medications were not administered according to the specified parameters, acknowledging the discrepancy during an interview.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5.00%, resulting in a 21.43% medication error rate. During an observation of medication administration, a registered nurse (RN) administered medications to a resident by crushing extended-release medications, which were listed on the facility's 'DO NOT CRUSH' list. The medications included Metoprolol Succinate Extended-Release and Oxybutynin Extended-Release. Additionally, the RN dispensed a Multi-Vitamin tablet that did not contain minerals, contrary to the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that these medications should not have been crushed and that the Multi-Vitamin tablet was incorrect. The resident's blood pressure and pulse were also not within the parameters specified for administering Metoprolol Succinate Extended-Release, yet the medication was still given. This incident highlights a significant deviation from the facility's medication administration policies and procedures, which require medications to be administered as prescribed and within pharmacy guidelines. In another instance, the same RN administered medications to a second resident, including Senna, Aspirin, Metformin, and Humulin R. The medications were administered significantly later than the scheduled times, with the Aspirin and Senna given approximately one and a half hours late and the Metformin administered two and a half hours late. The RN also crushed the medications and mixed them with applesauce before administration, despite the resident being able to take the medications whole. The DON was informed of the lateness of the medication administration. The facility's policies on administering oral medications and ensuring timely administration were not followed, leading to these medication errors.
Failure to Ensure Resident is Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident receiving intravenous medication was free from significant medication errors. Resident #54, who was admitted with diagnoses of Parkinson's Disease and an infection due to an internal left knee prosthesis, had a physician's order for vancomycin to be administered intravenously. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag. Staff H, a Registered Nurse and Unit Manager, was unable to explain why the medication was not fully administered or why the IV tubing was not labeled. Photographic evidence was obtained to document the observation. Further interviews with Staff G, another Registered Nurse and Unit Manager, and the Director of Nursing (DON) confirmed that the medication should have been fully administered and the IV tubing should have been labeled. The facility's policy on medication errors defines significant errors as wrong dose or omission, and the failure to fully administer the vancomycin to Resident #54 was acknowledged as a medication error. The progress notes did not document the amount of medication left in the bag, further indicating a lapse in proper medication administration procedures.
Failure to Assist Resident in Obtaining Routine Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, as evidenced by the condition of the resident's teeth and gums. The resident, who was cognitively intact according to the most recent Annual Minimum Data Set (MDS), was observed with several broken, chipped teeth, and dental caries. Despite these obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the resident's dental status. The resident had a small gradual weight loss over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical record did not document any referrals for dental consults or services, despite the facility having a dental service that visited monthly. Interviews with the Social Services Director and the Director of Nursing revealed that the facility's protocol for referring residents to dental services involved staff notifying the social worker if a dental problem was observed. However, in this case, the resident's dental issues were not identified or referred for a dental consult. The Social Services Director confirmed that the resident had not been referred to the dentist, and the Director of Nursing could not specify how often the contract dental service visited the facility. The lack of documentation and referral for dental care led to the deficiency identified in the report.
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What surveyors actually found near you
We read the 25 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
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Nursing homes near Avon Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks At Avon | 1.7 mi | ★★★★★ | 1 | 0 |
| Palms At Sebring Nursing And Rehabilitation The | 10.5 mi | ★★★★★ | 2 | 0 |
| Vivo Healthcare Sebring | 11 mi | ★★★★★ | 1 | 0 |
| Groves Center | 18.6 mi | — | 19 | 0 |
| Vivo Healthcare Wauchula | 18.7 mi | ★★★★★ | 0 | 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.