Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Seven Hills Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to obtain psychotropic medication consent for a resident with advanced cognitive impairment. A resident with Alzheimer’s disease, unspecified dementia, MDD, anxiety disorder, and pseudobulbar affect had orders for Zoloft, Trazadone, Depakote, and Melatonin, but the EMR did not contain psychotropic consent forms for Zoloft, Trazadone, or Depakote. The resident had a BIMS score of 3 and was documented as resistive to care, including refusing medications.
Unsanitary storage of resident care items and poorly functioning restroom plumbing were observed in 2 resident restrooms. In one shared restroom, a bedpan and 4 basins were left on the floor under the sink, unlabeled and unbagged, and remained there when the DON rechecked the area. In another restroom, a resident reported the toilet did not flush well and was clogged at times; staff observed incomplete flushing, and later the toilet seat was loose, feces were present, and the toilet still did not flush properly when the Administrator tried it.
Failure to obtain consent for abdominal binder restraints: Two residents with gastrostomy tubes were observed multiple times wearing abdominal binders covering the tubes, and records showed physician orders and care plan use of the binders to prevent tube removal. The MDS showed no restraint use, and there were no signed restraint consents. An LPN confirmed the binders prevented the residents from removing them, while the UM stated consent was not needed and that notifying family after the order was entered counted as consent, which conflicted with the facility’s restraint policy requiring a signed risk/benefit consent form.
Failure to Develop ADL Care Plan and Implement Swallowing Interventions: A resident with significant physical impairments had no ADL care plan despite needing extensive assistance with bathing, dressing, hygiene, and toileting, and the resident reported missed showers due to evening shift staffing. Another resident with swallowing precautions had cups with straws observed at the bedside even though the SLP recommended no straws for aspiration risk, and the care plan did not include the no-straw intervention.
A resident was observed receiving Jevity 1.5 via GT at 60 mL/hr, and the tube feeding bottle had the resident’s name and a date written on it. The product’s expiration date had passed, and an LPN confirmed the feeding was expired. The UM later stated she checked all tube feedings in the building and found no other expired products.
A resident who was independently mobile via wheelchair was found to be using a wheelchair with a torn back, exposed screws, and a seat cushion that was too small, leaving metal rods exposed at the front of the seat. The resident reported leg pain from feeling the metal against the thighs despite a cushion having been placed by therapy for comfort. Review of therapy and care plan documentation showed the resident had previously been fitted with a cushion and had a goal of no discomfort, but the OT later acknowledged that an appropriately sized cushion matching the wheelchair’s seat depth had not been available when the cushion was replaced.
The facility failed to ensure proper documentation and adherence to physician orders for wound care in three residents, resulting in missing or inconsistent entries in the treatment administration record, discrepancies between treatment plans and orders, and unperformed or undocumented wound care. Nursing staff and the DON acknowledged errors in order entry and documentation, and facility policies requiring accurate clinical documentation were not consistently followed.
The facility failed to provide a clean and homelike environment, with observations of cluttered hallways, dirty floors, and maintenance issues such as broken tiles and peeling paint. A resident experienced a persistent odor due to a clogging toilet and a malfunctioning air conditioning unit, highlighting lapses in maintenance and communication.
A resident with a PICC line was found with an overdue dressing change, contrary to physician's orders and facility policy. The dressing was dated over two weeks prior, appeared loose, and had a gauze underneath saturated with dried blood. The resident, admitted for orthopedic surgery aftercare with a significant medical history, could not recall the last dressing change. An LPN confirmed the dressing was overdue, highlighting a failure to adhere to professional standards of quality in central line care.
A facility failed to ensure physician orders for catheter care were in place for a resident with an indwelling catheter due to obstructive uropathy. The resident's care plan required catheter care, but no current orders were found in the MAR or TAR. Nursing staff were unaware of the lack of orders, and the oversight was acknowledged by the DON. The facility's policy required verification of physician's orders before performing catheter care, which was not followed.
The facility failed to ensure proper medication storage for two residents and in three medication carts. A resident had a medication cup with tablets on the bedside table without evaluation for self-administration safety, and another had unauthorized medications in the room. An unlocked medication cart and loose tablets in carts were also observed, violating the facility's storage policy.
A nurse failed to follow infection control protocols during glucometer use for three residents, not cleaning the device or performing hand hygiene between uses. This was against the facility's policy, which mandates cleaning and disinfecting the glucometer between each resident and handwashing before and after resident contact.
Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to inform and obtain consent for psychotropic medications for one resident. Resident #13 was observed in a wheelchair in the common area next to the nurse's station and was unable to answer interview questions at the time of observation. Record review showed the resident was admitted with diagnoses including Alzheimer's disease, unspecified dementia, major depressive disorder, anxiety disorder, and pseudobulbar affect. The resident had orders for Zoloft, Trazadone, Depakote, and Melatonin, and the MDS assessment showed a BIMS score of 3, indicating the resident rarely understands others and is rarely understood. The care plan documented resistive behaviors, including refusing to bathe, change clothes, and take medications, and noted impaired cognitive function, impaired thought processes, and aggression toward staff during care. A psychotropic consent form was present for Ativan 0.5 mg signed by the resident's representative and a consent form was present for Melatonin 3 mg, but no psychotropic medication consent form was found in the electronic medical record for Trazadone, Zoloft, or Depakote.
Unsanitary Storage of Resident Care Items and Poorly Functioning Restroom Plumbing
Penalty
Summary
The facility failed to store resident care equipment in a sanitary manner in 1 of 22 sampled resident restrooms, room [ROOM NUMBER]. During observation of the shared restroom on 3/3/26, one bedpan and 4 basins were found on the floor under the sink, and the items were not labeled or bagged. When the restroom was observed again on 3/5/26 with the DON, the bedpan and 4 basins were still on the floor under the sink and remained unlabeled and unbagged. The DON stated the bedpan and basins should be labeled for each resident and bagged separately. The facility also failed to maintain restroom plumbing in good working order in room [ROOM NUMBER]. On 3/2/26, the resident stated the toilet did not flush well and was clogged at times, and the toilet was observed not flushing completely. On 3/5/26, with the Administrator present, the toilet seat was loose, feces were present in the toilet, and the toilet did not flush properly when the Administrator attempted to flush it.
Failure to Obtain Consent for Abdominal Binder Restraints
Penalty
Summary
The facility failed to assess and obtain consent before using abdominal binders as restraints for two residents with gastrostomy tubes. Resident #3 was observed on multiple occasions with an abdominal binder covering the gastrostomy tube on the abdomen. The clinical record showed a physician order dated 10/24/25 for an abdominal binder and for staff to ensure it was on every shift for safety and placement, and the care plan stated the binder was used to keep the resident from pulling out the gastrostomy tube. Resident #149 was also observed multiple times with an abdominal binder covering the gastrostomy tube inserted into the abdomen. The clinical record showed a physician order for staff to verify abdominal binder placement every shift for gastrostomy tube protection, and the care plan listed an abdominal binder as indicated. For both residents, the minimum data set documentation showed no restraint use, and there were no signed consents for the use of the restraints. An LPN confirmed that the abdominal binders were in place to prevent the residents from pulling out their feeding tubes and stated that neither resident could remove the binders. The UM stated that residents with abdominal binders do not need consent and that notifying the family after entering the physician order into the computer was considered consent. The facility policy for physical restraints required that the resident and/or responsible party be provided information necessary to make an informed choice and that a restraint risk/benefit consent form be completed and signed indicating acceptance or refusal of the restraint device.
Failure to Develop ADL Care Plan and Implement Swallowing Interventions
Penalty
Summary
The facility failed to develop a plan of care for Resident #135 related to activities of daily living. Resident #135 was admitted with diagnoses including cerebral palsy, acute respiratory failure, left below-knee amputation, contracture of the right lower leg, and systemic lupus. A Minimum Data Set assessment completed on 12/26/25 showed impairment to both upper and lower bilateral extremities and documented that the resident required set-up assistance for eating, maximal assistance for oral hygiene, bathing, dressing, and personal hygiene, and was dependent on staff for toileting. During an observation and interview on 03/03/2026, the resident stated that he had not been getting showers due to not enough staff on the evening shift. On 03/04/2026, the MDS Coordinator reviewed the plan of care and confirmed that no care plan had been developed for activities of daily living. The facility also failed to implement care plan interventions for Resident #9. During an observation, the resident was seen in bed with a sign on the wall stating NO STRAWS and instructions for head positioning while eating or drinking, yet a cup of nectar-thick juice on the bedside table had a straw inside it. On a later observation, a white Styrofoam cup dated 3/4/26 was found next to the bed containing thin water with a straw inside. The Speech Therapist stated that Resident #9 was recommended to not use any straws because the resident was at high risk for aspiration, and that thickened liquids are ordered for residents with swallowing difficulties after evaluation for safe swallowing. Review of the care plan showed the resident was on a restorative nursing program for swallowing with a goal of safely consuming thin liquids with trained caregiver assistance, but the interventions did not include NO STRAWS and no physician order was noted on the medication record.
Expired Tube Feeding Infusing to Resident
Penalty
Summary
The facility failed to ensure that the tube feeding product had not exceeded the expiration date for enteral nutrition for Resident #149. During an observation of the resident, Jevity 1.5 was seen infusing at 60 milliliters per hour through the gastrostomy tube, and the bottle of tube feeding had the resident’s name written on it with a date listed on the bottle. The expiration date of the Jevity 1.5 being used was documented as expired. An LPN later confirmed that the tube feeding connected to the resident was expired. The Unit Manager also stated that after the expired tube feeding was observed infusing to Resident #149, she checked all tube feedings in the building and found no other expired tube feedings.
Failure to Maintain Safe and Properly Fitted Wheelchair Cushion
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and well-maintained wheelchair for a resident who was independently mobile via wheelchair. During observation, the resident’s wheelchair was noted to have tears on the back, a seat cushion that was smaller than the full depth of the seat, exposed metal rods on both sides at the front of the seat structure, and exposed screws bilaterally. Photographic evidence of these conditions was obtained. At the time of one observation, the resident was in bed with eyes closed while the deficient wheelchair condition was present. In an interview, the resident reported that a therapist had placed a cushion on the wheelchair because he was not comfortable, but the cushion was too small and caused leg pain because he could feel the metal against his thighs. Review of the care plan showed the resident was independent with wheelchair positioning, though he sometimes did not position himself appropriately. Occupational therapy documentation indicated services had been provided previously, with discharge notes stating the wheelchair had been fitted with a cushion and that the resident had achieved a goal of no discomfort for more than two hours. In a subsequent interview, the OT acknowledged that when the cushion was replaced, an appropriately sized cushion matching the approximately 18-inch seat depth was not available and confirmed that the cushion in use was not the proper size for the wheelchair.
Failure to Document and Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of care for wound management in three out of four residents reviewed. For one resident with a stage 4 sacral pressure ulcer and a non-pressure ulcer on the left third toe, there were discrepancies between the physician's treatment plan and the active orders in the medical record. The treatment administration record (TAR) did not include wound care for the left third toe, and documentation for coccyx wound care was missing on a specific date. The wound care nurse acknowledged that wound care was performed but not documented, attributing it to an oversight. Another resident with dementia and anxiety had an active physician order for coccyx wound care, but this order was not reflected in the TAR due to incorrect entry by nursing staff. The order was placed under the wrong section, resulting in the absence of documentation for wound care. The director of nursing confirmed that the order should have been discontinued as the resident no longer had a wound, but the lack of proper documentation and order management was evident. A third resident reported inconsistent wound care, stating that treatments were not performed as ordered. Review of the TAR showed missing documentation for wound care on multiple days, and the treatment frequencies entered did not match the physician's orders. The wound care nurse and DON acknowledged errors in order entry and documentation, with wound care not being documented or performed according to the prescribed schedule. Facility policies required accurate and timely documentation of wound care, which was not consistently followed in these cases.
Environmental and Maintenance Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by several observations during a survey. Numerous chairs and wheelchairs were found lining the hallways, creating potential tripping or entrapment hazards. In one room, the floor was visibly dirty, and the resident expressed discomfort with the condition. Another room had a bedside table missing a wheel and a wall corner in disrepair. Additionally, a resident reported that her wheelchair was missing and had not been returned promptly, despite staff being aware of the issue. Several rooms were noted to have broken tiles, peeling paint, and rust-like substances, indicating a lack of maintenance. In another instance, a persistent odor of feces was noted in a resident's room and the hallway, attributed to a repeatedly clogging toilet. The resident, who was independent in toileting, expressed embarrassment over the situation and had attempted to unclog the toilet himself. The air conditioning unit in the same room was not functioning properly, with the room temperature significantly higher than the set temperature. The Maintenance Director was aware of the toilet issue but not the air conditioning problem, indicating a lapse in communication and timely maintenance response.
Failure to Follow Physician's Orders for Central Line Care
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following physician's orders for central line care for a resident with a PICC line. During a facility tour, it was observed that the dressing on the resident's PICC line was dated over two weeks prior and appeared loose, with a gauze underneath that was saturated with dried blood. The resident could not recall when the dressing was last changed. The physician's orders specified that the PICC line dressing should be changed every 7 days during the day shift and as needed if soiled or dislodged. The resident, who was admitted for orthopedic surgery aftercare, had a significant medical history including diabetes, paraplegia, left leg amputation, anemia, and depression. An interview with an LPN confirmed that the dressing change was overdue according to the physician's orders. The facility's policy required central line dressings to be changed at established intervals and immediately if compromised, with gauze dressings to be changed every 2 days and transparent dressings every 5-7 days.
Failure to Ensure Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician orders for catheter care were provided in accordance with the care plan for a resident with an indwelling catheter. The resident, who had an indwelling catheter due to obstructive uropathy, was observed with a catheter drainage bag attached to his wheelchair. Upon review, it was found that there were no current physician orders for catheter care in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The last orders for catheter care and catheter change had been discontinued several months prior. Interviews with nursing staff revealed that there was confusion regarding the frequency of catheter care for the resident, and no active orders were located. It was suggested that the oversight might have occurred when the resident was discharged from hospice services, and the orders were not rewritten. The Director of Nursing acknowledged the oversight when informed of the issue. The facility's policy required nurses to verify physician's orders for catheter care before performing the procedure, which was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications for two residents and in three medication carts. For one resident, a medication cup containing four tablets was found on the bedside table, and the resident was not evaluated for medication self-administration safety. The resident had a significant medical history, including falls, diabetes, hypertension, anxiety, bipolar disorder, and depression. The staff member responsible for administering medications to this resident stated that she did not leave medications at the bedside and confirmed that the resident was not safe to self-administer medications. Another resident was found to have a bottle of Pepto Bismol and a tube of Hydrocortisone cream on the dresser, without physician orders for these medications and without an evaluation for self-administration safety. Additionally, an unlocked medication cart was observed in the hallway, and loose tablets were found in three different medication carts. The facility's policy requires drugs to be securely stored in locked cabinets or carts, and bedside drugs require a physician order and must be stored securely within the resident's room.
Infection Control Deficiency During Glucometer Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the medication pass involving glucometer use for three residents. Nurse A, a Registered Nurse, was observed using the same glucometer for multiple residents without cleaning or disinfecting it between uses. Specifically, during the procedures for Residents #337, #40, and #187, Nurse A did not clean or disinfect the glucometer before or after use, nor did she wash or sanitize her hands before or after performing the procedures. This was contrary to the facility's policy, which requires cleaning and disinfecting the glucometer between each resident use and performing hand hygiene before and after resident contact. The facility's policy for Capillary Blood Sampling and Handwashing, both dated 2001, clearly outline the necessary steps for infection control, including washing hands, using gloves, placing the glucometer on a clean field, and cleaning and disinfecting the equipment after each use. Despite these guidelines, Nurse A did not adhere to these protocols during the observed medication pass. The Director of Nursing was informed of these infection control concerns, and it was noted that training had been conducted with Nurse A regarding the proper procedures.
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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 Tallahassee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Tallahassee | 0.3 mi | ★★★★★ | 26 | 0 |
| Centre Pointe Health And Rehab Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Westminster Oaks | 1.2 mi | ★★★★★ | 14 | 0 |
| Aviata At The Gardens - Tallahassee | 1.5 mi | ★★★★★ | 10 | 0 |
| Tallahassee Memorial Hospital Extended Care | 2.4 mi | ★★★★★ | 0 | 0 |
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