Above average — CMS composite of the measures below.
The next survey window likely opens 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 Ruleme Center during CMS and state inspections, most recent first.
A resident's weights continued to be obtained even though the resident's representative had requested no further weights and a physician order was in place to stop weighing. An LPN confirmed the request and was unsure why weights kept being taken, and the DON confirmed the order for no more weights.
Unclean resident rooms and bathrooms: Surveyors observed brown rings around toilets, brown discoloration on tile, black and brown substances on baseboards and around AC units, dust and cobwebs in vents, stained floors, and scuffed, gashed, and peeling walls in multiple resident rooms. Residents and a representative stated housekeeping and maintenance had not cleaned the areas and that some conditions had been present since admission; one resident also reported rainwater entering the room from the AC area.
A resident with documented insomnia, depression, anxiety, PTSD, and other psychiatric diagnoses had an inaccurate PASRR Level I screen that indicated no mental illness. The DON stated that depression, anxiety, and PTSD must be written on the PASRR and that there was no PASRR policy.
A resident with a PICC line had a transparent dressing with gauze underneath it, and the dressing remained dated with no change noted during observations. An LPN later took a BP on the same arm directly over the PICC line, and staff interviews showed inconsistent understanding of central line dressing care and that BP should not be taken on an arm with a PICC line.
An LPN failed to perform hand hygiene after handling an item from the floor before giving an oral med, and staff did not wear a gown during G-tube med administration for a resident on EBP. In addition, nebulizer equipment for two residents was left uncovered or on the floor, and medication was left in a nebulizer chamber when a resident was not ready for treatment. Staff and the DON confirmed the expected infection control practices, and facility policies required hand hygiene, gown/glove use for high-contact care, and hygienic storage of nebulizer equipment.
A facility failed to ensure proper PPE use during high contact care for a resident on enhanced barrier precautions. An LPN was observed administering medication via a gastric tube with only gloves, despite EBP signage and available PPE. Interviews revealed non-compliance with the facility's policy requiring full PPE for residents with indwelling medical devices.
A resident with multiple health conditions, including dependence on supplemental oxygen, was found to be receiving oxygen at 4 liters per minute instead of the ordered 2 liters per minute. The incorrect administration was confirmed by a registered nurse, and there was no documentation supporting the increased oxygen level. The facility's policy requires adherence to physician orders, which was not followed.
A resident with severe cognitive impairment was found with medications left unsecured on her bedside table. The RN failed to ensure the resident swallowed her medications, which were later found moist, indicating they had been spit out. The resident's care plan and facility policy did not permit self-administration of medications due to her condition.
The facility failed to verify the licensure of a nurse, allowing her to work without a valid Florida license. The Human Resources Director did not thoroughly check the licensure requirements, and the nurse continued working beyond the allowed period. The Administrator and DON relied on HR to ensure staff qualifications, but this process failed, leading to a breach of professional standards.
A resident with serious health conditions, including a stage 4 pressure ulcer, had multiple instances of undocumented wound care treatments in their MAR over several months. Despite physician orders for daily wound care, facility staff interviews and policy reviews confirmed that treatments were not consistently documented, highlighting a failure to maintain accurate medical records.
The facility failed to ensure staff performed hand hygiene during medication administration, as observed in multiple instances involving an RN and LPNs. Staff were seen not using hand sanitizer or washing hands before and after administering medications, handling keys, and using medication carts and computers. Interviews revealed staff acknowledged their failure to adhere to hand hygiene protocols, despite the facility's policies and CDC guidelines emphasizing its importance in preventing infection spread.
Weights Obtained Despite Resident Representative Request and Physician Order
Penalty
Summary
The facility failed to ensure Resident #28's treatment choice was followed when weights continued to be obtained despite a physician order dated 6/18/2024 stating that the resident/resident representative requested no further weights be taken. Review of the resident's weight records showed weights were still obtained on multiple later dates, including 7/2/2024, 8/2/2024, 12/4/2024, 10/2/2025, 11/4/2025, 12/4/2025, and 1/7/2026. During interview, an LPN confirmed the resident's representative had requested no more weights be obtained and was uncertain why the weights continued after the request and physician order. The DON also confirmed the resident had a physician order for no more weights to be obtained.
Unclean resident rooms and bathrooms
Penalty
Summary
The facility failed to provide a clean and homelike environment in Hallway 200 based on multiple room observations and resident interviews. In one resident bathroom, surveyors observed a brown ring around the toilet and brown discoloration on a tile in front of the toilet. In another resident room, the baseboards had a brown and black substance around the entire room, there was black substance underneath and on top of the air conditioner, and a white cloth with brown substance, yellow, black, and brown substances, peeling paint, dust-like material, and cobwebs were protruding from the air conditioner vents. The resident stated housekeeping or maintenance had not been seen cleaning under, over, or inside the AC and vents, and reported that rain caused the room to flood with water coming from the AC area, requiring large commercial air blowers to dry the room. Additional observations showed two large brown spotted streaks on the tile floor in front of and between the wheels of one resident’s bed, along with large scuffs and gashes on the wall with chipping paint. The resident’s representative stated those streaks and wall damage were already present at admission and did not feel the room was home-like. Another resident room had a large round brown substance ring around the toilet and scuffs and gashes in the walls; the resident stated the toilet had been like that for a long time and believed wheelchair use was scraping the walls because there was not enough space between the wall and the beds. A separate room had black substance below the air conditioner and dust around the vents, and the resident stated housekeeping or maintenance had never cleaned those areas since admission. The Regional Maintenance Director, Acting Maintenance Director, Environmental Director, and Administrator acknowledged the environmental concerns and described expectations for clean baseboards, AC filters, vents, floors, toilets, bathrooms, and touchpoints.
Inaccurate PASRR Screen for Resident With Psychiatric Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not coordinated for a resident with newly evident or possible serious mental disorder, and an accurate Level I PASRR screen was not completed. The resident’s record showed an initial admission and readmission with diagnoses including psychophysiologic insomnia, major depressive disorder, PTSD, nightmare disorder, and generalized anxiety disorder. A psychiatry note documented a psychiatric history of insomnia, depression, anxiety, and PTSD. However, the resident’s PASRR dated 12/25/2025 documented no mental illness under Section I: PASRR Screen Decision-Making. During interview, the DON stated that depression, anxiety, and PTSD have to be written on the PASRR and that there was no policy for PASRRs.
Improper PICC Line Dressing Care and BP Taken Over PICC Line
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident #39, who had a PICC line in the right upper arm. During observation, the resident was lying in bed in a hospital gown with the PICC line dressing dated 1/19/2026, and a gauze pad was seen under the transparent dressing. The physician order for the PICC line required the dressing to be changed within 24 hours of admission, insertion, or reinsertion and every 7 days thereafter using sterile technique, with arm circumference and external catheter length measured. The resident was observed again the next day with the same PICC line dressing dated 1/19/2026 and a gauze pad still under the transparent dressing. Staff B, an LPN, then obtained a blood pressure reading on the resident’s right upper arm directly over the PICC line. Staff C, an LPN Unit Manager, stated that she would not use gauze for a central line dressing change, although gauze pads came in the central line dressing kits. The DON stated that the standard of care was to change a central IV line dressing every 72 hours if gauze was under the transparent dressing and that staff were not to take blood pressure on the arm with a PICC line. Staff B later stated she was aware it was not standard of care to take a blood pressure reading over a PICC line.
Infection Control Failures During Medication Administration and Respiratory Equipment Storage
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during medication administration and used appropriate PPE during high-contact care for residents on enhanced barrier precautions. During an observation, an LPN picked up an item from the floor and disposed of it, then administered ferrous sulfate to one resident without performing hand hygiene. During another observation, staff crushed four tablets and administered them via G-tube to another resident while not wearing a gown, even though the resident was on EBP. The DON stated that a gown is to be worn for medication administration via G-tube and that hand hygiene is to be performed prior to medication administration. The facility policy for EBP states that gown and glove use is required for high-contact resident care activities, including device care or use such as a feeding tube, and the medication administration policy requires staff to follow infection control procedures such as handwashing and antiseptic technique. The facility also failed to store respiratory care equipment in a hygienic manner for two residents receiving nebulizer treatments. One resident's nebulizer mask and tubing were observed lying on the floor after a breathing treatment, and later the same equipment was again observed on the floor. Another resident's nebulizer mask was observed hanging from the nebulizer machine, uncovered, with medication still in the chamber, and it remained uncovered on later observations. The resident stated she had received her breathing treatment earlier and did not want it at that time. Staff stated that if a resident refuses the nebulizer, the medication should not be placed in the chamber until the resident is ready, and that the nebulizer needs to be covered after it has dried for storage. The DON stated that the nurse should administer the nebulizer in the room and not leave medication in the chamber, and that the nebulizer has to be covered when not in use. The facility's nebulizer policy states that nebulizer tubing should be stored in a hygienic manner when not in use.
Failure to Use Proper PPE During High Contact Care
Penalty
Summary
The facility failed to ensure that staff used proper personal protective equipment (PPE) while providing high contact care to residents on enhanced barrier precautions (EBP). During an observation, a Licensed Practical Nurse (LPN) was seen administering medications into a resident's gastric tube while only wearing gloves, despite the presence of EBP signage on the door and available PPE, including gowns and masks, in the hallway. The facility's policy requires the use of gowns and gloves during high contact resident care activities, especially for residents with indwelling medical devices such as feeding tubes. Interviews conducted with the LPN and the Assistant Director of Nursing (ADON) revealed a lack of adherence to the facility's PPE policy. The LPN admitted to sometimes wearing gowns, while the ADON confirmed that all PPE, including gloves, gowns, and masks, should be worn during such procedures. The facility's policy, issued in March 2024, clearly outlines the necessity of using EBP for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility staff failed to administer oxygen to a resident as per the physician's order. The resident, who was admitted with multiple diagnoses including anemia, dysphagia following a stroke, quadriplegia, and dependence on supplemental oxygen, had a physician's order for continuous oxygen administration at 2 liters per minute via nasal cannula. However, during observations on two separate occasions, the resident was found to be receiving oxygen at 4 liters per minute, which was not in accordance with the physician's order. The oxygen concentrator was placed outside the resident's reach, and there was no documentation indicating a need to increase the oxygen level or any change in the resident's respiratory status. Staff A, a registered nurse, confirmed the incorrect oxygen rate and acknowledged the oversight, stating that the oxygen should have been set at 2 liters per minute as ordered. The Director of Nursing also stated that staff are expected to assess residents on oxygen daily to ensure compliance with physician orders. The facility's policy on oxygen administration requires adherence to physician orders and facility protocols, which was not followed in this instance.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored in one of the residential halls, specifically Hall 100. During an observation, a resident was found with a plastic cup lid containing five different pills on her bedside table. The resident, who has severe cognitive impairment, was unable to self-administer medications safely. The medications were identified as Trazodone, Iron Pill, Clopidogrel, a blood pressure medication, and Isosorbide. The registered nurse, Staff A, admitted to administering the medications earlier but did not ensure the resident swallowed them, as evidenced by the moist pills that had been spit out. The resident's medical records indicated a history of cerebral infarction, dementia, psychotic and mood disturbances, anxiety, muscle weakness, diabetes with neuropathy, repeated falls, and heart disease. The resident's care plan highlighted her communication problems, elopement risk, and behaviors such as spitting out medications. The facility's policy requires a physician's order for residents to self-administer medications, which was not present for this resident. The Director of Nursing confirmed that the resident was not capable of self-administering medications due to cognitive impairment, and emphasized the expectation for nurses to ensure medications are taken and documented properly.
Failure to Verify Nurse Licensure
Penalty
Summary
The facility administration failed to ensure that all staff members were properly licensed, leading to a deficiency in the quality of care provided. Specifically, the administration did not verify the licensure status of a nurse, referred to as Staff A, who was hired as a Registered Nurse but did not possess a valid Florida license. This oversight allowed Staff A to work in the facility without the necessary credentials, as observed during a survey when Staff A was seen working at a medication cart with a name tag indicating the position of Registered Nurse. The Human Resources Director admitted to not thoroughly checking the licensure requirements, mistakenly believing that Staff A had 60 days to obtain a Florida license. However, Staff A continued to work beyond the allowed period without securing the appropriate licensure. Interviews with the Administrator and the Director of Nursing revealed that they relied on the Human Resources department to ensure all staff were fully qualified before employment, but this process failed in the case of Staff A. The deficiency was further compounded by a misunderstanding on the part of Staff A, who believed that merely submitting an application for a Florida license was sufficient to begin working. This misinterpretation, combined with the facility's failure to adhere to regulatory requirements for verifying licensure, resulted in a breach of professional standards and regulations, compromising the quality of care provided to residents.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure accurate and complete medical records for a resident who was reviewed for wound care. The resident, who was admitted with multiple serious health conditions including necrotizing fasciitis and a stage 4 pressure ulcer, had several instances where wound care treatments were not documented as completed in the Medication Administration Record (MAR). Specifically, treatments were not documented on multiple dates across several months, despite physician orders specifying daily wound care procedures. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that all dressing changes and treatments should be documented immediately upon completion. The facility's policy on documentation, revised in January 2024, also mandates that all services provided to residents be recorded in their medical records to facilitate communication among the interdisciplinary team. However, the lack of documentation for the resident's wound care treatments indicates a failure to adhere to these standards.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during medication administration, as observed in multiple instances. On several occasions, a Registered Nurse (RN) and Licensed Practical Nurses (LPNs) were seen not performing hand hygiene before and after administering medications to residents. This included failing to use hand sanitizer or wash hands after exiting resident rooms and before preparing medications for other residents. The staff members were observed handling keys, medication carts, and computer keyboards without performing hand hygiene, which is a critical step in preventing the spread of infection. During interviews, the staff members acknowledged their failure to adhere to hand hygiene protocols. One RN admitted to not using hand sanitizer when administering medications, while an LPN recognized the need to wash hands before and after glove use. Another LPN expressed nervousness as a reason for not performing hand hygiene. These admissions highlight a lack of compliance with the facility's infection control policies, which require hand hygiene before and after direct resident contact and when hands are not visibly soiled. The Director of Nursing (DON) confirmed the expectation that all nurses follow the infection control policy for handwashing. The facility's policies, including those on medication administration and hand hygiene, emphasize the importance of hand hygiene as a measure to prevent infection spread. The policies align with CDC guidelines, which recommend handwashing or the use of alcohol-based hand rubs in healthcare settings. Despite these guidelines, the observed actions of the staff did not comply with the established procedures, leading to the identified deficiency.
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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 Eustis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Waterman | 1.2 mi | ★★★★★ | 1 | 0 |
| Avante At Mt Dora, Inc | 1.4 mi | ★★★★★ | 11 | 0 |
| Lake Eustis Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 10 | 2 |
| Bayview Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Edgewater At Waterman Village | 2.7 mi | ★★★★★ | 9 | 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.