Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sea Breeze Rehab And Nursing Center during CMS and state inspections, most recent first.
Informed consent for psychotropic medications was not properly obtained or documented for two residents. One resident with cognitive impairment and orders for lorazepam and trazodone had no consent form in the chart, despite repeated requests during survey, while another resident’s consent paperwork was incomplete and did not list the psychotropic medications or clearly indicate consent. The DON stated the facility had changed forms, but acknowledged the resident should have had documentation for each psychotropic medication added before the change.
Failure to Honor Resident Shower and Hygiene Preferences: Multiple residents with varying levels of cognitive and physical impairment did not receive showers or bathing care consistent with their care plans and stated preferences. Records showed missed or infrequent showers, inconsistent task documentation, and residents or family members reporting long gaps without bathing, while staff described unclear or inconsistent shower scheduling and documentation practices. Several residents stated they had not had a shower in weeks, and one resident was observed with dirty, greasy hair before later receiving a shower.
Failure to Maintain Resident Dignity During Care and Dining: Staff were observed standing over residents while assisting with meals, referring to residents as “feeders” in the hallway, administering an IM injection in a hallway with the resident’s clothing pulled down, and entering a resident’s room for catheter care without knocking or introducing themselves. One resident with intact cognition reported an LPN shoved medication into his mouth and ignored his request for repositioning, while another resident with dysphagia and cognitive impairment was observed being fed in a manner staff acknowledged was not appropriate.
A facility failed to maintain multiple resident rooms in a safe, clean, and homelike condition. Surveyors observed dirty windows, bubbling paint and crumbling bathroom walls, an unused oxygen concentrator still plugged in and tagged do not use, a resident bathroom with signs of a ceiling leak and a bucket on the toilet, stained and sticky flooring, damaged molding, and a strong foul odor in one room; the ADON and other staff acknowledged several of these conditions.
Delayed Response to Resident Grievances: The facility did not timely process grievances for three residents with intact cognition. A resident reported a missing weight loss medication, another resident’s family raised multiple concerns including a missing spray bottle, broken vase, and consent issue, and a third resident reported that an LPN shoved meds into his mouth and failed to assist with repositioning. Staff accounts showed the concerns were not promptly routed or investigated under the grievance process.
PRN psychotropic orders were not limited to 14 days for two residents. One resident with cognitive impairment and diagnoses including anxiety, depression, and brief psychotic disorder had Lorazepam PRN orders with no end date while staff observed the resident calling out for help in a geri chair. Another resident with intact cognition had Alprazolam and Temazepam PRN orders without specified stop dates, and pharmacy reviews noted the missing stop dates before the meds were later discontinued.
Two residents with moderate cognitive impairment were observed with overgrown, unclean fingernails despite needing ADL assistance. One resident’s nails were jagged, extended about 1/2 inch past the nail edge, and had brownish-yellow debris, while the other resident’s nails extended about 1/4 inch past the fingertips with discoloration under the nails. Staff and the residents stated the nails had not been properly cut and cleaned, and one CNA acknowledged the nails were too long and dirty.
Incomplete wound care documentation and delayed medication administration: A resident with a wound infection had an incomplete treatment order that did not identify the wound location, and the TAR lacked documentation for several treatment days. Another resident with skin issues had no clear physician order for left arm care. In addition, pharmacy recommendations not to crush certain meds were not reflected in the orders, and multiple residents received scheduled meds outside the facility’s timing window; the DON acknowledged meds were not being given in a timely manner.
Failure to follow catheter care orders for two residents: one resident’s chart showed missed monitoring and catheter care documentation, and the record continued to document catheter care after the catheter had already been removed. Another resident had several shifts with no documented catheter care, and surveyors observed the catheter drainage bag hanging from the bed facing the open door with no privacy cover in place. An LPN stated a privacy cover was always needed, and the ADON acknowledged missed documentation.
A resident with dysphagia and a feeding tube had physician orders for continuous enteral nutrition and scheduled water flushes, but the MAR showed missing documentation for multiple shifts and the nursing notes contained no tube feeding documentation. An LPN stated missed tube feeding should be reported and documented, while the ADON believed the resident was still receiving tube feeding until an observation showed no feeding hung and the resident said he had not received tube feeding since Friday because he was now eating by mouth.
Bed Rails Placed Without Required Assessment, Orders, Consent, or Care Plans: Surveyors found multiple residents with bed rails or enablers on their beds without the required assessment, MD order, consent, or care plan. Residents had varied diagnoses including CVA-related hemiplegia, paraplegia, Parkinson’s disease, CHF, COPD, dementia, and depression, and several assessments left key questions blank or documented that side rails were not necessary while the rails remained in place. Staff interviews showed inconsistent processes for assessing, ordering, and removing bed enablers.
Controlled drug records were not kept in order for a resident with a right femur fracture who had an order for PRN Tramadol. The med was signed out on the control record, but there was no MAR documentation showing it was administered, and an LPN stated narcotics are signed out when removed from the med cart and signed off on the MAR once given.
A facility failed to respond promptly to the consultant pharmacist’s MRR recommendations for a resident’s Lidocaine patch order. The pharmacist repeatedly asked for the order to specify the application site and to include a 12-hours-on/12-hours-off schedule to avoid medication error and tachyphylaxis, but the order remained written as apply to the affected area topically once daily for pain. The Medical Director said the facility had misplaced many of the original pharmacy recommendations, and the DON said some MRRs were hard to locate because they were stored inconsistently or had to be resent by the pharmacist.
A facility failed to monitor and document behaviors and side effects for two residents receiving psychotropic medications. One resident with cognitive impairment and diagnoses including anxiety, depression, and psychotic disorder was observed repeatedly calling out, trying to get out of a Geri chair, and appearing restless and agitated, yet the MAR/TAR contained no behavior or side-effect documentation. Another resident with dementia, depression, anxiety, and suicidal ideations had an order for every-shift psychotropic side-effect monitoring, but progress notes did not document side effects or physician notification.
Medication administration errors exceeded the allowed rate, with surveyors finding wrong-route doses, omitted meds, and an incorrect dose during observed med passes and record review. One resident received several enteral meds orally and had multiple omitted meds, while another resident missed metformin doses when the drug was unavailable and received the wrong dose of vitamin B-12; both residents were cognitively intact.
Medications and supplies were left unsecured on multiple occasions. An unlocked med cart was observed unattended with residents and a visitor nearby, another cart was left unlocked with keys on top, and an LPN left a cart unlocked while giving meds to a resident and also left Senna unattended in the room. During an Accu-Chek for a resident with DM, the LPN left the glucometer and supplies exposed on the cart and later entered the room without relocking the cart. A resident with COPD and other diagnoses also had inhalers kept at bedside instead of secured.
An LPN failed to clean and disinfect resident-care equipment after checking a resident’s BP and after using a glucometer for another resident, and also failed to perform hand hygiene during medication administration for two residents. During observations, the LPN returned a BP cuff to the med cart without cleaning it, cleaned a glucometer incorrectly after use, and prepared/administered medications without washing hands, including after assisting a roommate and handling medication items.
The facility failed to honor the shower preferences and schedules for two residents, leading to a deficiency in promoting resident self-determination. One resident, who was cognitively intact but later showed signs of confusion, received only three showers over a month despite being scheduled for twice-weekly showers. Another resident, also cognitively intact, did not receive any showers in the past month despite a similar schedule. Both residents expressed a desire for more frequent showers, and the DON confirmed the lack of documentation for showers or refusals.
The facility failed to maintain a safe, clean, and homelike environment in Unit B, as observed by surveyors. Issues included rusted IV poles, stained furniture, improperly wrapped call light cords, and debris under chair cushions. The Director of Maintenance acknowledged these findings during a facility tour.
A resident reported missing clothes after sending them to the laundry, but the facility failed to address the grievance. Despite informing staff, including the previous Social Worker and CNAs, no action was taken until the surveyor's involvement. The DON was unaware of the issue and acknowledged that no grievance had been filed, contrary to the facility's policy requiring prompt resolution of grievances.
The facility failed to ensure accurate MDS assessments for three residents. A resident was incorrectly coded as comatose, while two others had inaccuracies regarding dental and hearing status. These errors were identified through interviews and observations, revealing discrepancies between the MDS assessments and the residents' actual conditions.
The facility failed to develop care plans for two residents, one with hearing impairment and another self-administering medication. A resident with hearing issues had no care plan despite being identified as having impaired hearing. Another resident was allowed to self-administer Creon without a proper assessment or care plan, contrary to facility policy. Staff interviews revealed inconsistencies in the process for assessing and documenting self-administration capabilities.
The facility failed to document the removal of narcotics in the MARs for three residents, leading to discrepancies between the medication monitoring control records and the MARs. A resident with a physician order for Oxycodone HCl had undocumented medication removal on a specific date, while another resident with an order for Oxycodone Acetaminophen had missing documentation for a medication removal and administration. Additionally, a third resident with a Hydrocodone-Acetaminophen order had discrepancies in documentation, confirmed by the DON.
A resident with dementia and metabolic encephalopathy eloped from the facility, crossing a busy street to another nursing home. Despite documented wandering and exit-seeking behaviors, the incident was not recorded in the facility's logs, and the investigation was insufficient. Staff interviews revealed a lack of awareness of the resident's elopement risk, and the facility failed to determine how the resident exited the building.
Informed Consent for Psychotropic Medications Not Properly Documented
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications was obtained for two residents receiving such medications. One resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized anxiety disorder, major depressive disorder, and brief psychotic disorder, and had a BIMS score of 9 indicating moderate cognitive impairment. Physician orders included lorazepam and trazodone, but the record contained no informed consent for psychotropic medications on admission, and multiple requests during the survey for the consent documentation were not met with any record provided. During observation, the resident was seen reclined in a Geri chair repeatedly calling out for help and attempting to get out of the chair, and later told the surveyor, "help me, I want to get out of this chair." The DON stated medical records, admissions, and MDS did not have the consent record. A second resident was admitted with diagnoses including major depressive disorder, anxiety disorder, COPD, hypertension, and muscle weakness, and had current and prior orders for psychotropic medications including Trileptal, fluoxetine, chlorpromazine, and trazodone. The chart contained a Psychoactive Medication Informed Consent form signed by the resident, but the form was incomplete because the statement indicating whether the resident wanted or did not want the medication was not checked and the medications were not listed. The record also contained a Psychotropic Medications Use: Risks vs Benefits document, and the DON stated the facility had stopped using the Psychoactive Medication Informed Consent form and used the Risk & Benefit form instead, while acknowledging the resident should have had documentation for each psychotropic medication added before that change.
Failure to Honor Resident Shower and Hygiene Preferences
Penalty
Summary
The facility failed to honor resident rights and resident choice related to bathing and showers for multiple residents. The report states that, based on observation, interview, policy review, and record review, the facility did not ensure showers and/or shower preferences were honored for 6 of 7 sampled residents: Residents #15, #40, #38, #81, #95, and #112. The facility policy required appropriate care and services for residents unable to perform ADLs independently, including bathing and showers, with resident consent and in accordance with the plan of care and resident preferences. Resident #15 had diagnoses including acute systolic heart failure, cardiomegaly, and an implanted cardiac defibrillator, and had a BIMS score of 10 indicating moderate cognitive impairment. His baseline care plan required limited to extensive assistance with bathing and showering, and he stated he had difficulty getting staff to give him a shower, had no scheduled shower day, and had only 1-2 showers during his stay. The shower task did not list days or shift, while a paper schedule in a binder listed Monday and Thursday on 3-11. Review of the past 30 days showed only 6 showers/baths, with only one on a scheduled shower day, and no refusals documented. Resident #38, who had diagnoses including COPD, muscle weakness, hip fracture, hepatic failure, hypoglycemia, and MI, had intact cognition and was assessed as needing partial/moderate assist for showers and baths, yet stated he had not had a shower in weeks and wanted one. Resident #81, with diagnoses including Parkinson’s disease, cervical spinal stenosis, depression, anxiety, muscle weakness, dysphagia, and hypertension, had intact cognition and a care plan calling for limited to extensive assist with bathing. Her shower task showed no showers or full baths for the prior 30 days, only 2 sponge baths, and she stated she had not had a shower in 3 weeks and cried when asked about it. Resident #112, who had diagnoses including hypothyroidism, CAD, hypertension, pulmonary embolism, cachexia, hemiplegia/hemiparesis following cerebral infarction, diabetes, COPD, Sjogren syndrome, heart failure, and vascular dementia, was dependent on staff for bathing and showers. Her shower/bath task sheet showed no showers or baths since admission, and she stated she had not had a shower and did not know it was an option; her hair was observed dirty and greasy before she finally received a shower later in the day. Resident #95, with diagnoses including paresthesia of skin, CHF, hypertension, pneumonitis, dysphagia, depression, and diabetes, had intact cognition and required substantial to maximal assist with showers. His shower task showed only one shower and two partial sponge baths over the review period, and he stated he had never been offered or given a shower before going to the hospital and could not have showers after returning because of a permanent plasma port. Resident #40, who had diagnoses including ischemic cardiomyopathy, chronic systolic CHF, depression, anxiety, mood disorder, and paranoid schizophrenia, had intact cognition and preferred showers as very important. Her care plan called for shower/bed bath per preference on shower days, but the CNA task showed only 5 showers, 2 full bed baths, and 12 entries marked not applicable, with a 2-week gap and no refusals documented. Her family member reported she sometimes went 3 weeks without showers or change of clothing, and the resident was observed in bed with oily, unclean hair and stated she had not received a shower that day and preferred morning showers. Resident #29, who had intact cognition and was dependent for toileting hygiene and clothing, stated staff told her they changed residents every two hours but she had to wait until a scheduled time even when she needed to be changed, and she reported staff turned off her call light and told her to wait.
Failure to Maintain Resident Dignity During Care and Dining
Penalty
Summary
The facility failed to treat residents in a dignified manner during dining, medication administration, and catheter care. The report cites observations, interviews, and record reviews showing that staff stood over residents while assisting with meals, referred to residents as “feeders” in the presence of others, administered an IM injection in a hallway with the resident’s clothing pulled down to expose his shoulder, and entered a resident’s room for catheter care without knocking or introducing herself. Resident #49, who had diagnoses including hemiplegia, intracranial hemorrhage, anxiety disorder, dysphagia, aphasia following cerebral infarction, seizures, muscle weakness, and cognitive communication deficit, had a BIMS score of 13 indicating intact cognition. During breakfast observation, a CNA was seen standing over him while assisting him with eating. When questioned, the CNA stated she did not know he was a feeder and did not know they should not stand up over residents when feeding them. Resident #95, who had diagnoses including CHF, HTN, pneumonitis due to inhalation of food and vomit, dysphagia, major depressive disorder, and diabetes, had a BIMS score of 15. He reported that an LPN shoved medication into his mouth and refused his request for assistance with repositioning a sore area and placing a pillow under his back. The report also states that an LPN gave an IM injection to Resident #53 in the hallway after pulling down the resident’s shirt and sweater to expose his shoulder, and that during catheter care for Resident #95, the ADON entered the room through a closed door without knocking or introducing herself. In addition, during lunch tray distribution, CNAs were overheard referring to residents as “feeders” in the hallway within range of other residents and family members.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to ensure residents' rooms were maintained in a safe, clean, and homelike environment for 13 of 60 rooms, including Rooms 210, 202, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, and 128. An observation of a window in one room showed dark matter covering the window to the outside, and the Assistant Director of Nursing later acknowledged the window was dirty. In another room, the bathroom wall by the toilet tissue holder had bubbling paint and a crumbling wall with no paint along the length of the wall. An unused oxygen concentrator was also observed with its plug running under the bathroom door and plugged into an outlet in the bathroom, with a tag stating it was removed from service and not to be used; the Assistant Director of Nursing acknowledged it should have been removed in March 2026. In a resident's bathroom, the resident stated there was a leak coming from the ceiling and that a gray bucket was placed on top of the toilet to catch water, which the resident said had been emptied 3 days earlier. Observation showed a discolored ceiling tile, a vent above the toilet, and stained floors and walls in the bathroom. During a later tour, the Housekeeping District Manager and Facilities Housekeeping Manager observed discoloration around the toilet and stained walls and alerted the Maintenance Director about the ceiling tile and bucket. On the unit with Rooms 100-110, surveyors observed stained tile floors, sticky flooring inside some resident rooms, and damaged molding with missing paint. Staff also acknowledged a strong foul odor in one room and stated that new flooring had been approved for the 100 unit but had not yet been replaced.
Delayed Response to Resident Grievances
Penalty
Summary
The facility failed to implement its Grievance-Resident Rights policy for three sampled residents by not providing timely responses to grievances and complaints. The policy stated that the Administrator and staff would make prompt efforts to resolve grievances and that the Grievance Officer would review and investigate allegations and submit a report to the Administrator within five working days of receiving a grievance or complaint. The report documented that grievances involving Residents #60, #25, and #95 were not handled in a timely manner as required by the facility’s policy. Resident #60 was admitted with diagnoses including obesity, unilateral primary osteoarthritis, and generalized anxiety disorder, and had a BIMS score of 15, indicating intact cognition. The resident reported that her weight loss medication had disappeared on 03/27/26 and stated that staff, including an RN who worked that day, knew about the missing medication. Interviews showed that the SSD first learned of the missing medication on 05/03/26, and staff gave differing accounts about whether the medication had been discarded or discontinued. A grievance form for this issue was not initiated until after surveyor intervention, and it was dated 05/04/26 with the grievance occurrence listed as 03/27/26. Resident #25 was admitted with diagnoses including major depressive disorder, anxiety disorder, COPD, hypertension, and muscle weakness, and had intact cognition on admission MDS. The grievance log showed one grievance about a missing Febreze spray bottle, but the resident’s relative stated that multiple verbal grievances had been made to the SSD, including concerns about the missing Febreze, a broken vase, and an incomplete psychotropic consent form. Additional grievances for the broken vase and outing issue were not found until 05/04/26 after surveyors were in the building. Resident #95 was admitted with diagnoses including paresthesia of skin, CHF, hypertension, pneumonitis, dysphagia, major depressive disorder, and diabetes type II, and also had a BIMS score of 15. A grievance described that an LPN shoved medications into the resident’s mouth and did not assist him when he asked to be repositioned with a pillow; however, staff stated the concern was written by a CNA and placed under the DON’s door on 04/30/26, and the SSW stated she did not hear about the grievance until surveyors informed her.
PRN Psychotropic Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure PRN antipsychotic/psychotropic medication orders were limited to 14 days for Resident #109 and Resident #39. Resident #109 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, generalized anxiety disorder, major depressive disorder recurrent moderate, and brief psychotic disorder. A BIMS assessment documented moderate cognitive impairment. The physician orders included Lorazepam 1 mg by mouth every 8 hours as needed with no end date, and another Lorazepam 1 mg order every 6 hours as needed with no end date. During observation, the resident was reclined in a geri chair repeatedly calling out for help, attempting to get out of the chair but unable to do so, and was also observed with a contracted left hand while staff walked past without acknowledging her. Resident #39 was admitted with diagnoses including paraplegia, colostomy, hypertension, major depressive disorder, anxiety disorder, and chronic kidney disease, and had a BIMS score of 15/15 indicating intact cognition. The physician orders showed Alprazolam 0.25 mg every 8 hours as needed for anxiety and Temazepam PRN, both discontinued on 05/01/26. Pharmacy reviews in March and April 2026 noted that the Alprazolam PRN and Temazepam PRN orders did not have specified stop dates, and the physician agreed with the pharmacist's findings on both occasions but did not add a stop date before the medications were discontinued.
Inadequate Fingernail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to complete ADLs independently received appropriate nail care, including having fingernails cut and cleaned. The policy on ADL Care and Services stated that residents unable to carry out ADLs independently were to receive assistance with hygiene, including nail care. Resident #98 was admitted with diagnoses including a left radius fracture, generalized muscle weakness, and cognitive communication deficit, and had a BIMS score of 12 indicating moderate cognitive impairment. On observation, Resident #98’s fingernails were untrimmed, jagged, extended about 1/2 inch past the nail edge, and had a brownish-yellow substance under them. The resident stated he needed his nails cut, smoothed, and cleaned but could not do it himself and no staff had offered to help. A CNA later stated the nails were too long and dirty and needed to be cleaned and cut. Resident #21 was admitted with diagnoses including hypertension, acute kidney failure, and history of falling, and had a BIMS score of 10 indicating moderate cognitive impairment. During observations, Resident #21’s fingernails were about 1/4 inch past the fingertips with discoloration under the nails. The resident stated staff had taken away his fingernail clippers, which was why his nails were long, and later said he trimmed and cleaned his nails himself. A CNA stated the resident had scratched his nose and that the scab kept reopening, and when asked about the nails, initially said they were not that long but then agreed they were too long. The CNA also stated she had offered to cut the nails, but the resident wanted to clip them himself and had lost his clippers; she further stated there was no excuse and she should have clipped the nails last week or made sure he got the clippers.
Incomplete wound care documentation and delayed medication administration
Penalty
Summary
Wound care orders were not clarified and wound care was not documented for a resident with an amputated right leg, peripheral vascular disease, and a left foot wound infection. The physician order dated 04/08/26 directed staff to soak the wound with Dakins 0.25% solution for 10 minutes, rinse with normal saline, and apply wet-to-dry dressings every day shift, but the order did not identify the wound location. The Treatment Administration Record showed no documentation that the treatment was performed on 04/15/26, 04/28/26, and 05/01/26, and on 05/04/26 the nurse entered code 9, "Other/See Nurse Notes," without a corresponding nursing progress note. The Assistant DON later acknowledged the order was incomplete because it did not state the wound location and that the wound care documentation had not been recorded for several days. Skin assessment monitoring was not completed weekly for a resident with hemiplegia, hemiparesis, diabetes, chronic respiratory failure, aphasia, dysphagia, bipolar disorder, and major depressive disorder. Weekly skin checks documented a reopened area to the left shoulder on 03/22/26 and a fall on 03/25/26, but the record review and interviews showed no current physician order for the resident's left arm despite staff describing wound care being provided to that area. During interview, an RN stated the resident scratches his arms and described wound care being done without identifying any physician order for the left arm. Medication administration was not consistent with pharmacy recommendations and several residents did not receive medications within the facility's timing parameters. For one resident, pharmacy consultant recommendations stated that ferrous sulfate, tamsulosin, and pantoprazole should not be crushed, but the physician agreed with the recommendations and the orders were never changed; the RN stated she crushed ferrous sulfate and Flomax and gave them in applesauce. For three residents, multiple scheduled medications were administered outside the one-hour-before to one-hour-after window, including medications such as Toprol XL, aspirin, fluticasone-salmeterol, lisinopril, venlafaxine, gabapentin, escitalopram, buspirone, clonazepam, carbidopa-levodopa-entacapone, lidocaine patch, diclofenac gel, and prednisone. The DON acknowledged that medications were being administered outside the 2-hour perimeter and were not given in a timely manner.
Failure to Follow Catheter Care Orders
Penalty
Summary
The facility failed to follow physician orders for indwelling urinary catheter care and monitoring for two residents. One resident was admitted with diagnoses including UTI and obstructive/reflux uropathy and had orders to monitor the catheter every shift and provide catheter care every shift and as needed. The treatment record showed missed documentation of monitoring and catheter care on some shifts, and after the catheter was removed on 04/30/26, the record continued to show catheter monitoring and care documented on multiple shifts in early May even though no catheter was present. During observation, the resident was sitting up in bed without an indwelling catheter, and the resident stated the catheter had been removed the prior week. The ADON acknowledged the resident had an active/current catheter care order and that it had not been documented as done in a couple of days. A second resident had an order for indwelling urinary catheter care every shift and as needed, and the care plan identified a risk for injury/infection related to the presence of the catheter. The treatment record showed no documentation of catheter care on several shifts in April and May. During observation, the resident was sitting up in bed with the catheter drainage bag suspended from the side of the bed facing the open door, the bag was more than half full of yellow liquid, and there was no privacy cover in place. An LPN stated that a drainage bag needed a privacy cover always, and the ADON acknowledged there were dates when catheter care was not documented as performed for this resident.
Tube Feeding Orders Not Followed or Documented
Penalty
Summary
The facility failed to ensure physician’s orders for tube feeding were followed and updated for a resident with dysphagia and a feeding tube. Resident #95 was admitted with diagnoses including acute on chronic diastolic congestive heart failure, dysphagia, disease of the pericardium, and venous insufficiency. The resident’s care plan dated 03/22/26 stated the resident required tube feeding related to dysphagia, with goals to maintain adequate nutritional and hydration status and remain free of side effects or complications related to tube feeding. The interventions included following physician orders for nutrition and flushes, and keeping the resident NPO except for thin liquid drinks at bedside, with straw use permitted. The physician’s order dated 03/26/26 directed continuous enteral nutrition with Jevity 1.5 at 65 mL/hr for a total volume of 1300 mL and 150 mL water flushes every 4 hours via pump. However, the MAR showed no documentation for tube feeding on multiple shifts, including the 3:00 PM to 11:00 PM shift on 05/02/26, 05/03/26, and 05/04/26, and the 11:00 PM to 7:00 AM shift on 05/04/26. Other entries included codes for medication on order from pharmacy and MD aware, hold/see nurse notes, and drug refused. Nursing progress notes from 04/28/26 to 06/03/26 contained no documentation regarding tube feeding. During interview, an LPN stated that if tube feeding was not given according to orders, the physician would be notified and the issue documented in the nurse progress notes. The ADON later stated the resident was still on tube feeding, but during a side-by-side observation there was no tube feeding hung or being administered, and the resident stated he had not had tube feeding since Friday because he was now eating by mouth.
Bed Rails Placed Without Required Assessment, Orders, Consent, or Care Plans
Penalty
Summary
The facility failed to ensure that bed rails were properly assessed, ordered, consented to, and care planned for 6 of 6 sampled residents who had bed rails or bed enablers in place. The report states that for Residents #3, #39, #49, #81, #95, and #112, the facility did not obtain the required assessment for bed rails, physician orders, consent, or a completed care plan. Survey observations confirmed that each of these residents had bed rails or enablers on their beds during the survey. Resident #3 was admitted with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, type II DM, chronic respiratory failure, aphasia, dysphagia, bipolar disorder, and major depressive disorder. The annual MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The care plan included side rails as ordered to promote functional bed mobility, and the resident was observed with bed rails in the up position on both sides of the bed. However, the reentry nursing assessment stated that side rails were not necessary at that time, the question about whether the resident would benefit from side rails was left blank, and the question about whether the resident/representative understood the risks and benefits and consented was also left blank, although a consent dated 05/01/26 was present. Resident #39 had diagnoses including paraplegia, HTN, CKD, major depressive disorder, lack of coordination, muscle weakness, gait and mobility abnormalities, and anxiety disorder, with a BIMS score of 15. The resident’s bed had enablers on both sides, but the nursing admissions assessment only documented that the resident needed side rails to promote independence and that the alternative tried was bed in the lowest position. The consent was signed on the day surveyors entered the building, and there were no physician orders for the siderails. Resident #81, with Parkinson’s disease, cervical spinal stenosis, major depressive disorder, generalized anxiety disorder, muscle weakness, dysphagia, and HTN, was also observed with bed enablers on both sides of the bed. Her nursing admission assessment stated she could have side rails and that the only alternative tried was bed in the lowest position, but there was no consent or physician order for the bed rails. Resident #112 had diagnoses including hypothyroidism, CAD, HTN, pulmonary embolism, cachexia, hemiplegia and hemiparesis following cerebral infarction, lack of coordination, type II DM, COPD, Sjogren syndrome, HF, and vascular dementia. The MDS had not yet been completed. The resident was observed with bed enablers on both sides of the bed, but the nursing admissions assessment left blank the questions about whether the resident would benefit from side rails and whether the resident/representative understood the risks and benefits and consented. The assessment listed bed in lowest position and frequent rounding as alternatives tried, and stated side rails were not necessary at this time, yet a consent dated 05/01/26 was present and there were no physician orders. Resident #95, with diagnoses including paresthesia of skin, CHF, HTN, pneumonitis, dysphagia, major depressive disorder, and type II DM, was also observed with bed rails on both sides of the bed. The initial nursing assessment left blank the questions about benefit and consent, documented bed in lowest position as the alternative tried, and stated side rails were not necessary at this time. Resident #49, with hemiplegia, non-traumatic intracranial hemorrhage, anxiety disorder, pneumonitis due to inhalation of food and vomit, dysphagia, aphasia following cerebral infarction, seizures, muscle weakness, and cognitive communication deficit, had two bed rails on the bed. The admissions nursing assessment said the resident would benefit from enablers, listed bed/bolster/wedges as alternatives tried, and had a consent signed, but there were no physician orders and no care plans for the siderails. During interviews, the Maintenance Director stated that bed rails were not put on unless there was a care plan in place, but also said the nurse puts in a work order for the rails and that he did not read each care plan. The agency LPN stated that admission assessments include discussion of the pros and cons of bed rails and that therapy/administration does an assessment if the patient requests them. The Director of Rehab stated that side rail assessments are only done on residents they feel will need one, otherwise nursing completes them on admission. The DON stated that if the resident wants bed enablers they can have them and acknowledged having a stack of consents signed on the day surveyors entered the building. Surveyors also observed six empty rooms with discharged beds still having enablers on them, and an Assistant Maintenance staff member stated that the enablers were only removed when the facility received a list, which was not very often.
Controlled Drug Record Discrepancy
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for Resident #87. Resident #87 was admitted with diagnoses including Displaced Intertrochanteric Fracture of the Right Femur, and had a physician order dated 04/17/26 for Tramadol HCl 50 mg, 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Review of the Medication Monitoring Control Record showed Tramadol was signed out on 04/26/26, but the Medication Administration Record had no documentation that Tramadol was administered on that date. During interview on 05/06/26 at 5:00 PM, an LPN stated that when a narcotic is removed from the med cart it is signed out on the Medication Monitoring Control Record, and once it is given, it is signed off on the MAR.
Failure to Act on Pharmacist Recommendations for Lidocaine Patch Order
Penalty
Summary
The facility failed to respond to the consultant pharmacist’s medication regimen review recommendations for Resident #4’s Lidocaine external patch order. Resident #4 was admitted and readmitted to the facility with diagnoses including chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and primary generalized osteoarthritis. The pharmacist recommended that the Lidocaine patch order be clarified to include a specific site of administration to avoid medication error and that it be applied once daily for 12 hours and then removed for 12 hours to avoid tachyphylaxis. The medication regimen review record showed the pharmacist made the same recommendations on more than one occasion, and the physician did not sign and agree with the recommendations until several months later. The physician’s order remained for Lidocaine External Patch 4% to be applied to the affected area topically one time a day for pain, and the MAR documented nurses applying the patch to the affected area topically one time a day. During interviews, the Medical Director stated the facility had misplaced many of the original pharmacy recommendations, and the DON stated she had difficulty finding the medication regimen reviews because some were signed and stored in the binder while others had to be resent by the pharmacist.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects
Penalty
Summary
The facility failed to monitor behaviors and side effects for two residents receiving psychotropic medications. Resident #109 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized anxiety disorder, major depressive disorder, and brief psychotic disorder, and had a BIMS score of 9 indicating moderate cognitive impairment. Physician orders included multiple psychotropic medications, including lorazepam and trazodone, along with an order to monitor and document behaviors and psychotropic medication side effects every shift. Record review for Resident #109 showed no documentation of behaviors or side effects in the MAR/TAR despite the monitoring order. The behavior symptoms task record documented no behaviors on one shift, but surveyor observations showed the resident repeatedly calling out for help, attempting to get out of a reclined Geri chair, and appearing restless and agitated while staff walked past or stated the resident was on 1:1 observation. Staff also reported the resident had been trying to undress herself and had been agitated throughout the night. Resident #12 was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia, major depressive disorder, dementia, anxiety disorder, suicidal ideations, and adult failure to thrive. The resident’s MDS showed a BIMS score of 15 and indicated use of an antipsychotic, antianxiety, antidepressant, antiplatelet, insulin, and anticonvulsant medications. Although there was a physician order to monitor psychotropic medication side effects every shift, the MAR showed mixed entries of yes and no, and nurses’ progress notes from the reviewed period contained no documentation of side effects or physician notification for significant changes.
Medication Error Rate Exceeded Threshold With Wrong-Route, Omitted, and Incorrect-Dose Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying a 34.48% error rate based on 10 medication errors out of 29 observed opportunities. The deficiency involved two residents and included wrong-route administration, omitted medications, and an incorrect dose during observed medication passes and record review. For one resident with diagnoses including acute on chronic diastolic CHF, dysphagia, disease of the pericardium, and venous insufficiency, the BIMS score was 15, indicating intact cognition. During an observed morning med pass, Effer K, multivitamin with minerals, midodrine hydrochloride, and thiamine were administered orally even though the orders directed administration via G-tube or PEG tube. During the later med pass, apixaban was also given by the wrong route, and aspirin 81 mg chewable, cholecalciferol 5,000 units, and Saccharomyces boulardii were omitted. The LPN stated that medications should be given exactly as ordered and that enteral medications should not be given orally without an order change. For another resident with DM2, generalized weakness, depression, hypertension, and muscle wasting/atrophy, the BIMS score was 14, indicating intact cognition. During observation, metformin 500 mg was not available in the cart and was not administered, and the MAR showed it was overdue; record review also showed it was not given on two documented days, with no documentation that the pharmacy or provider were contacted. In addition, cyanocobalamin was administered at 100 mcg instead of the ordered 250 mcg. The Medical Director stated he would expect to be notified if a resident did not receive medication for any reason.
Medications Left Unsecured on Carts and in Resident Rooms
Penalty
Summary
Medications and biologicals were not kept secure at all times. On multiple observations, medication carts were left unlocked and unattended, including one cart left unlocked with two residents and a visitor in the hallway, another left unlocked with keys on top of it, and a third left unlocked and unattended. During medication pass observations, an LPN left a medication cart unlocked and unattended while administering medications to Resident #95 in the resident’s room, and later left a bottle of Senna on the counter in the resident’s room while she stepped out to get gloves. The LPN stated the carts should be locked at all times and that medications should never be left unattended. Resident #29 had diagnoses including Type 1 Diabetes Mellitus with Ketoacidosis without Coma and had an order for Insulin Glargine 100 units/mL, 11 units subcutaneously twice daily. During an Accu-Chek observation, an LPN removed the glucometer, strip, lancet, and gloves from the medication cart, locked the cart, then placed the glucometer and other supplies on top of the cart and went into the resident’s room to assist another resident, leaving the supplies exposed and out of her line of sight. She later entered Resident #29’s room without relocking the cart. Resident #38, who had diagnoses including COPD, muscle weakness, hip fracture, hepatic failure, hypoglycemia, and myocardial infarction, had an inhaler observed on an over-bed table and later another inhalation medication observed at bedside; the resident stated he kept the Albuterol nearby and later acknowledged it needed to be locked up along with the other medication.
Failure to Clean Resident-Care Equipment and Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to follow its policy for cleaning and disinfecting resident-care equipment after obtaining a blood pressure and heart rate for a resident with HTN, hyperlipidemia, and type 2 DM. During a medication administration observation, an LPN gathered a BP wrist cuff, entered the resident’s room, obtained the BP and HR, and then returned the cuff to the medication cart without properly cleaning it before dispensing the resident’s medications. The resident had orders for Amlodipine Besylate 10 mg daily and Metoprolol Succinate ER 25 mg daily, with the Metoprolol to be held for HR less than 60. The facility also failed to follow the correct cleaning and disinfection method for a multi-resident use glucometer after a blood sugar check for another resident with a history of atherosclerotic heart disease, type 1 DM with ketoacidosis without coma, and atrial fibrillation. During the Accu-Chek observation, the LPN performed hand hygiene, donned gloves, completed the blood sugar test, discarded sharps, and washed her hands. She then used an alcohol wipe to clean the glucometer and returned it to the medication cart, despite the manufacturer’s instructions stating the meter should be cleaned and disinfected between each patient using the specified procedure. The facility also failed to ensure hand hygiene during medication administration for two residents. For one resident with hemiplegia and hemiparesis following cerebral infarction, cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, persistent mood disorders, and metabolic encephalopathy, the LPN prepared multiple medications, crushed them individually, opened a probiotic capsule, and administered the medications without performing hand hygiene. For another resident with HTN, hyperlipidemia, and type 2 DM, the LPN prepared 11 medications without hand hygiene, entered the resident’s room, assisted the roommate to the bathroom while wearing gloves, removed the gloves, and then handled the resident’s empty medication cup without washing her hands. The LPN acknowledged not washing her hands during the medication administration observation.
Failure to Honor Resident Shower Preferences and Schedules
Penalty
Summary
The facility failed to honor the shower preferences and schedules for two residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #14, who was cognitively intact upon admission but later showed signs of cognitive confusion, was scheduled for showers twice a week but only received three showers over a thirty-day period. The resident expressed a desire for more frequent showers but was unaware of the shower schedule. The CNA responsible for Resident #14 stated that showers and refusals were documented in the computer, but the Director of Nursing confirmed the lack of documentation for showers or refusals. Similarly, Resident #48, who was cognitively intact and expressed the importance of choosing between a bath and a shower, did not receive any showers in the past thirty days despite being scheduled for showers twice a week. The resident reported having only one shower since November and expressed a desire for two to three showers a week. The CNA working with Resident #48 was unaware of the resident's shower schedule and did not offer a shower during the scheduled shift, instead providing a bed bath. The Director of Nursing also confirmed the lack of documentation for showers or refusals for this resident.
Facility Fails to Maintain Safe and Clean Environment in Unit B
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in Unit B, as observed by surveyors on multiple occasions. On January 8th, an IV pole in one room was found to be rusted at its base. In another room, a resident's spouse reported that chairs in the sitting room next to the nurses' station were in poor condition, with trash and stained seats, which was confirmed by the surveyor's observations. Additionally, a bathroom door was noted to squeak, and a bedside table was stained with a white substance, with another IV pole also showing rust. Further observations revealed that the black caulking around a toilet base was coming away and had debris in the gap, a remote control was frayed, and a call light cord was improperly wrapped around a handrail, making it unusable. A privacy curtain between beds was stained with a brown substance. These findings were acknowledged by the Director of Maintenance during a facility tour, who noted that the black caulking was intended to match the floor and that the call light cord would be replaced.
Failure to Address Resident Grievance on Missing Personal Items
Penalty
Summary
The facility failed to respond to a verbal grievance regarding missing personal items for a resident, identified as Resident #13. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported missing clothes, including 8 dresses and 3 skirts, after sending them to the laundry. Despite the resident's attempts to inform the previous Social Worker and Certified Nursing Assistants (CNAs) about the missing items, the grievance was not addressed or documented by the facility. During an interview, the Director of Nursing (DON) expressed surprise upon learning about the missing clothes and acknowledged that no grievance had been filed for Resident #13. The resident confirmed having communicated the issue to staff members, but no action was taken to resolve the grievance. The facility's policy requires prompt efforts to resolve grievances, but in this case, the grievance was not addressed until the surveyor's involvement.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents. Resident #14 was incorrectly coded as comatose in the MDS assessment, despite no evidence supporting this status in the medical record. The error was attributed to the previous Social Service Director, who was no longer employed at the facility. The current MDS Coordinator, who was new to the facility, was unaware of the error until it was brought to her attention. Resident #82's MDS assessment inaccurately documented the resident as having natural teeth, while observations and interviews confirmed the resident was edentulous, with only metal posts in place. Similarly, Resident #87's MDS assessment inaccurately documented adequate hearing and the presence of natural teeth, despite the resident reporting significant hearing impairment and being observed without teeth. These inaccuracies were identified during interviews and observations, highlighting discrepancies between the MDS assessments and the residents' actual conditions.
Deficiencies in Care Planning for Hearing and Medication Self-Administration
Penalty
Summary
The facility failed to develop and implement care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #87, who was admitted with a diagnosis including Wedge Compression Fracture and Muscle Weakness, was identified as having impaired hearing during the admission evaluation. However, no care plan was developed to address her hearing concerns, despite her stating she was deaf in one ear and had limited hearing in the other. The MDS Coordinator acknowledged the absence of a care plan for hearing issues, which should have been in place. Resident #15, who was cognitively intact with a BIMS score of 14, was allowed to self-administer Creon, an enzyme replacement medication, without a proper assessment or care plan. The facility's policy required an assessment by the Attending Physician and the Interdisciplinary Care Planning Team to determine the resident's capacity to self-administer medication safely. However, there was no documented assessment or care plan for Resident #15's self-administration of Creon, and the medication administration record indicated unknown self-administration. The B-Unit Manager admitted to completing an assessment on paper due to computer issues, but it lacked necessary details and evidence of IDT participation. Interviews with staff revealed a lack of clarity and consistency in the process for assessing and documenting residents' ability to self-administer medication. The Regional Clinical Consultant confirmed that the process should involve a nursing assessment followed by care planning with the IDT, but this was not documented for Resident #15. The absence of proper documentation and care planning for both residents highlights deficiencies in the facility's ability to meet the residents' needs effectively.
Failure to Document Narcotic Removal in MARs
Penalty
Summary
The facility failed to ensure proper documentation of narcotic removal in the medication administration records (MARs) for three residents. Resident #28 had a physician order for Oxycodone HCl to be administered via peg-tube every four hours as needed for chronic pain. However, there was a discrepancy between the medication monitoring control record and the MARs, as the removal of the medication on January 3rd at 10:57 AM was not documented in the MARs. Similarly, Resident #6 had a physician order for Oxycodone Acetaminophen for non-acute pain, but the MARs lacked documentation for the removal and administration of the medication on January 4th at 6:30 PM. Resident #9 had a physician order for Hydrocodone-Acetaminophen for non-acute pain, with discrepancies noted between the medication monitoring control record and the MARs. The MARs did not document the removal and administration of the medication on January 1st at 8:15 PM. An interview with the Director of Nursing confirmed the lack of documentation for the narcotic removal, indicating a failure in maintaining accurate medication records for these residents.
Failure to Prevent Elopement and Inadequate Investigation
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident with a history of dementia, metabolic encephalopathy, and alcohol abuse. The resident, who was assessed as a low risk for elopement, exhibited wandering and exit-seeking behaviors. Despite these behaviors being documented in progress notes, the resident managed to leave the facility without staff knowledge and supervision, crossing a busy street to another nursing facility. The incident was not captured in the facility's incident log, and the investigation conducted was inadequate. The facility did not identify the event as an elopement, and the investigation failed to determine how the resident exited the building. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, and the surveillance video was not properly utilized to ascertain the details of the incident. The facility's failure to thoroughly investigate the root cause of the elopement and to report the adverse event as required by state and federal regulations contributed to the deficiency. Additionally, the care plan was not updated with appropriate interventions, such as one-to-one supervision, to prevent future occurrences.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vero Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vero Beach Care Center | 0 mi | ★★★★★ | 16 | 0 |
| Palm Garden Of Vero Beach | 0.1 mi | ★★★★★ | 2 | 0 |
| Hidden Lakes Senior Living Community | 0.6 mi | ★★★★★ | 12 | 0 |
| Garden View Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At Indian River Estates | 5.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.