Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Unsanitary Rooms and Offensive Odors: Surveyors observed a strong urine odor throughout the facility, with repeated findings of dirty floors, food debris, broken blinds, exposed outlets and wiring, leaking and rusted bathroom fixtures, mold-like substances, peeling paint, and other unsanitary conditions in multiple rooms on the 300 and 400 units. The patio area also had broken, rotted fencing, exposed rusted nails, and overgrown vegetation, and the Administrator stated the area was not safe for residents.
A resident was repeatedly observed in heavily soiled clothing and on soiled bedding with a strong urine odor over multiple days, despite stating they had requested assistance with changing and hygiene. The resident, who had moderate cognitive impairment and occasional incontinence but required staff help with bathing, grooming, toileting, and incontinence care, was left in the same dirty clothes and linens, and at one point reported having to change themselves due to lack of staff response. The care plan did not specify the level of ADL assistance needed, laundry was left in bags for nursing staff to distribute rather than returned to the room, and the DON reported expectations for 2-hourly rounding and ADL care but confirmed there were no written ADL or resident care policies.
Failure to report resident elopement involving law enforcement response. A resident exited through a bedroom window and was seen outside on facility property before staff and police escorted him back. The DON stated the event was not reportable because staff maintained visual contact and the resident did not leave the grounds, but a police report confirmed law enforcement responded and assisted with the return.
Failure to provide incontinence and ADL care: A resident with a hx of stroke, seizure disorder, psychotic disorder, depression, anxiety, repeated falls, and moderate cognitive impairment was repeatedly observed in wet and soiled clothing with urine odor over several days. The resident said he asked staff for help changing but no one came, and his room and bed were also soiled with urine. The care plan did not identify his needed level of assistance, while an LPN stated he required help with bathing, dressing, grooming, toileting, and incontinence care; the DON stated staff were expected to provide frequent rounding and incontinence care every 2 hours and as needed.
Surveyors found that the Memory Care unit was not kept clean or comfortable, with food debris and sticky floors throughout, and a resident's room containing a dirty mattress and stained bedsheet. A PCA was performing housekeeping duties due to staff absences, and both the DON and an RN acknowledged the inadequate cleanliness.
Multiple residents voiced ongoing concerns about the repetitive menu and limited food options, filing a formal grievance through the Resident Council. Despite documentation of complaints and an investigation that involved sending evidence to corporate, the grievance remained unresolved, and staff interviews revealed a lack of awareness and follow-up regarding the issue, contrary to the facility's grievance policy.
A resident's room was found to have damaged baseboards held together with tape and a bed frame with extensive rust, while maintenance staff failed to identify or address these issues during routine checks. The maintenance log only reflected unrelated minor repairs, and no new beds had been ordered despite claims to the contrary.
Surveyors found that the facility did not develop or implement complete, person-centered care plans for several residents with complex medical and behavioral needs. For example, a resident with dementia and behavioral complaints had no care plan interventions addressing these issues, and other residents lacked care plans for conditions such as limited range of motion, safe smoking with oxygen, and disease-specific needs. The DON confirmed that care plans were missing or incomplete for multiple residents.
A resident who required moderate to maximum assistance with personal hygiene, dressing, grooming, and oral care was repeatedly observed with unkempt hair, stained clothing, visible food particles, and poor oral hygiene. Despite a care plan outlining the need for staff assistance with these activities, the resident was not provided adequate support, resulting in ongoing unmet needs.
A resident with a left hand contracture and history of CVA did not receive appropriate range of motion care, as repeated observations showed no splints or devices were applied and no restorative program was in place. Staff interviews confirmed that restorative care was inconsistent due to staffing issues, and record review showed the resident had significant functional limitations without a maintenance program.
A resident with a newly placed AV fistula for dialysis did not receive consistent monitoring of the fistula's bruit and thrill by nursing staff. Despite discharge instructions to check the site daily, documentation showed assessments occurred only on three occasions, and there were no physician's orders for monitoring until nearly a month after placement. The DON confirmed the lack of orders and ongoing assessment prior to that time.
A resident with hepatic encephalopathy and liver cirrhosis did not receive prescribed rifaximin on multiple days because the medication was not available from the pharmacy. After missing several doses, the resident experienced increased confusion, tremors, and a decline in self-care, resulting in transfer to a hospital for altered mental status. Facility records and staff interviews confirmed the medication was unavailable for several days prior to the resident's transfer.
The facility did not provide documentation that several residents received education or were offered the pneumococcal vaccine, as required by policy. Review of medical records and staff interviews confirmed that forms indicating education, consent, or declination were missing for these residents.
The facility did not provide documentation showing that several residents received education about and were offered the COVID-19 vaccine, as required by policy. Interviews with nursing leadership confirmed that such documentation should be present in the medical record, but it could not be located for the affected residents.
Two resident rooms were found to have privacy curtains that were too short in width to ensure full visual privacy between beds, as confirmed by facility staff during an observation. The Administrator acknowledged the expectation for each room to provide complete visual privacy.
The facility failed to conduct annual performance reviews and training for a CNA, identified as Staff Member D, who was unable to recall her last training on resident rights and working with cognitively impaired residents. The DON confirmed that evaluations and training were only completed recently, with no prior documentation available.
The facility failed to promote resident dignity and quality of life by not allowing residents to wear personal clothing, not providing enough clean clothes, and restricting movement at night. A resident was found unclothed and distressed over lack of assistance, while others reported issues with soiled linens and rude night staff. The DON acknowledged these concerns.
A linen shortage in the facility affected resident care, with several residents lacking clean clothing and bed linens. Staff reported difficulties in obtaining necessary linens, and observations confirmed poorly stocked linen rooms. The Maintenance Director acknowledged the issue, citing delays in linen orders due to administrative approval processes.
The facility failed to resolve grievances promptly for several residents, as required by their policy. Grievances included inappropriate staff behavior, lack of assistance, and issues with medication and personal care. These grievances were not documented or investigated, and the Social Services Director responsible was terminated for not performing these duties.
The facility failed to provide timely assistance with daily living activities, including hygiene and nail care, due to staffing shortages. Residents were found in soiled conditions, with some reporting infrequent baths and falls due to lack of assistance. Staff interviews confirmed inadequate staffing, particularly on evening and night shifts, impacting care quality.
The facility failed to provide sufficient staffing to meet residents' basic needs, resulting in inadequate assistance with daily living activities such as bathing, dressing, and oral hygiene. Residents reported long wait times for help, missed showers, and unsanitary conditions. Staffing shortages, particularly during evening and night shifts, led to unmet care needs and compromised hygiene, as corroborated by staff interviews.
A facility failed to develop a comprehensive care plan for a resident requiring wound care. Despite having a physician's order for wound treatment, the resident's care plan lacked goals and interventions for wound care. A review confirmed the oversight, which was against the facility's policy requiring comprehensive care plans with measurable objectives.
A facility failed to obtain lab results for a resident after a physician ordered tests for CBC, BMP, and Hemoglobin A1c. The Treatment Administration Record indicated the blood sample was collected, but no results were found in the medical records. The DON requested the results, but they were not provided, and an RN confirmed the absence of lab results despite the completed documentation.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsanitary Rooms and Offensive Odors
Penalty
Summary
The facility failed to provide an environment that was free of offensive odors and failed to maintain a sanitary and clean environment in multiple resident rooms on the 300 and 400 units, as well as the patio outside the 400 unit. On entrance to the facility, surveyors noted a strong, pungent urine-like odor throughout the building, with the smell stronger on the 200, 300, and 400 halls. The odor was again observed during unit tours, and the same findings were documented on repeated observations over several days. On the 300 unit, surveyors observed torn flooring, food particles, and a butter knife in the hallway. Multiple rooms had broken blinds, exposed sockets, missing outlet covers, boards covering windows, and uncovered light fixtures. In several bathrooms, surveyors observed dark brown stains on walls, rusted ceiling tile trim, corrosion on sink faucets and pipes, leaking fixtures, wet flooring around toilets, black mold-like substances near toilet bases and on walls, peeling paint, rusted sprinkler heads, and toilet components that were taped, loose, or improperly fitted. One resident bed appeared dirty with a black substance on the foot of the bed, and another room had a dresser drawer facing sitting on the floor next to the dresser. On the 400 unit, surveyors observed a strong urine odor upon entry through the locked unit doors. Bathrooms had missing ceiling tiles, broken emergency light covers, toilet tank covers that did not fit properly, torn toilet paper and used briefs on the bathroom floor, brown rust-like substances in toilet bowls, cracked door facings with brown substances, and brownish-blackish buildup around toilet bases with broken or peeling trim. Additional findings included broken blinds, exposed wiring with no outlet covers, loose flooring, leaking sinks, rusted pipes, unmade beds, uncovered light fixtures, and a dry red substance on a bathroom door frame. The outside patio walkway and fencing also showed broken and rotted boards, unsteady railings, exposed rusted nails, and overgrowth of limbs and bushes coming through the fence. The Administrator stated the area was not safe for residents and that it was planned to be redone later in the summer.
Failure to Provide Timely Personal Care and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care and personal care services to maintain grooming and hygiene for one resident. Surveyors observed the resident on multiple occasions in visibly soiled clothing with a strong odor of urine. On one afternoon, the resident was seen standing in his doorway with navy pants wet from the seat down to both calves, reporting he had been waiting for staff to change his clothes. Later that same day, he was still in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, the resident was again observed wearing the same soiled clothes, smelling of urine, with his shirt soiled with food and a dark liquid. His room had a strong urine odor, and his bed was soiled with urine. Only two pairs of pants were seen in the room, and no other clothing was observed. On a subsequent observation, the resident was seated on the edge of his bed wearing khaki pants and no shirt, with yellow-soiled sheets beneath him and his previously soiled red shirt and navy pants on the floor at the end of the bed. The resident stated he had requested assistance with changing clothes but staff had not come, so he changed himself. Record review showed a history of multiple medical conditions and a recent Quarterly MDS indicating a moderate level of cognitive impairment, with the resident moderately independent for toileting, personal hygiene, and other ADLs, and occasionally incontinent. The resident’s care plan did not specify the level of staff assistance required for personal care and ADLs. An LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and incontinence care, did not refuse care, and appropriately requested help. The LPN also explained that laundry staff left clean, labeled clothing in bags in the linen room for nursing staff to distribute. The DON stated that staff were expected to perform rounds every two hours and as needed, keep residents clean and dry, and provide all needed ADL care, but acknowledged the facility had no written ADL, resident care, or quality of care policies.
Failure to Report Resident Elopement Involving Law Enforcement Response
Penalty
Summary
The facility failed to notify state and federal agencies of an incident involving a resident who exited the facility through his bedroom window and walked across the facility property toward the perimeter fence. A CNA saw the resident outside and called for assistance, and staff redirected him back to the facility where he was placed on one-to-one supervision. Facility maintenance inspected the window seals in the resident’s room after the incident. The investigation did not include staff or witness statements for review. The resident later recalled leaving the facility and stated that a police officer told him not to leave the facility again. A police report obtained from the local police department documented that law enforcement encountered the resident outside the facility and assisted staff in escorting him back without incident. During interviews, the DON stated she did not believe the event was reportable because staff had visual contact with the resident and he never left the grounds, although she later acknowledged that law enforcement responded to the incident and that such events were required to be reported.
Failure to Provide Incontinence and ADL Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain grooming and incontinence care for one resident who was observed repeatedly wearing wet and soiled clothing over multiple days. The resident was seen standing in the doorway of his room with navy-colored pants wet from the seat down both legs to the calves and had a strong odor of urine. Later the same day, he was observed in the same soiled pants and shirt seated in a wheelchair near the nurses’ station. The next day, he was again observed wearing the same soiled clothes, smelling of urine, with a shirt soiled with food and a dark liquid. His room had a strong urine odor, the bed was soiled with urine, and only two pairs of pants were seen in the room. On the following day, he was observed seated on the edge of his bed wearing khaki pants and no shirt, with soiled yellow sheets underneath him and his prior soiled clothing on the floor at the end of the bed. The resident stated that he had asked staff for help changing clothes but no one came, so he had to change himself. His record showed a history of stroke, seizure disorder, anxiety, depression, psychotic disorder, and repeated falls. The most recent MDS indicated a BIMS score of 10, showing moderate cognitive impairment, and documented him as independent for toileting, showering, personal hygiene, and dressing, while also noting occasional bowel and bladder incontinence. The care plan did not identify the level of assistance he required for incontinence care or other ADLs. An LPN stated that the resident did require staff assistance with bathing, dressing, grooming, toileting, and incontinence care, and confirmed that he did not refuse personal care and was compliant in requesting staff assistance. The DON stated staff were expected to provide frequent rounding and incontinence care every two hours and as needed, but the facility did not have an ADL policy, resident care policy, or quality of care policy.
Failure to Maintain Clean and Homelike Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the Memory Care unit (400 Hall) was not maintained in a clean, comfortable, and homelike condition. During a facility tour, floors throughout the unit, including the dining area and all resident rooms, were found to have food debris and were sticky. One resident room had a mattress on the floor with fall mats, and both the mattress and mats were dirty, with the bedsheet visibly stained. Staff interviews revealed that a Personal Care Assistant was performing housekeeping duties due to the absence of regular housekeeping and maintenance staff, who had called out sick. The Director of Nursing confirmed the staff shortage, and a Registered Nurse acknowledged that the cleanliness of the unit was inadequate, specifically noting the state of the floors and rooms. These observations and staff statements directly indicated a failure to provide a safe, clean, and homelike environment for residents in the Memory Care unit.
Failure to Address Resident Council Grievance Regarding Food Quality and Variety
Penalty
Summary
The facility failed to act upon a grievance filed by the Resident Council regarding the variety and quality of food served. During a meeting with Resident Council members, multiple residents expressed ongoing dissatisfaction with the food, citing repetitive menus, limited alternate meal options, and the discontinuation of certain preferred items such as fried chicken. Residents reported that their complaints about food quality and variety had been raised multiple times, including in council meeting minutes and a formal grievance, but the issues persisted. The grievance investigation noted that pictures of portion sizes and repetitive menu items were sent to corporate, and a plan was made to work with the contracted food service company to improve offerings, but the grievance remained unresolved and residents continued to express dissatisfaction. Interviews with facility staff revealed a lack of awareness and follow-through regarding the grievance. The Dietary Manager was unaware of the specific grievance and stated that menu changes were routine and not in response to resident concerns. The Social Services Director confirmed ongoing complaints and stated that the grievance was reported to corporate, but could not provide evidence of any measures taken to resolve the issue or follow-up with residents. The facility's grievance policy requires prompt efforts to resolve complaints and inform residents of progress, but there was no documentation showing that these steps were taken in response to the Resident Council's food-related grievance.
Failure to Maintain Safe and Sanitary Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a safe and sanitary manner in one of the resident rooms. During observation, the baseboards in the room were found to be damaged, cracked, and held together with blue painter's tape, while the bed frame of one resident was extensively rusted, covering more than half its length. Maintenance Employee A reported conducting daily rounds to check exit doors and hallways and reviewing the maintenance log at each nurse's station, but was unaware of the extent of the rust on the bed and the damaged baseboards. The maintenance log only noted a need for replacement light bulbs in the room, and although Employee A entered the room to replace the bulbs, he did not notice or document the other issues. The Administrator initially stated that beds were on order but later confirmed that no beds had actually been ordered.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all identified needs for multiple residents. For one resident with dementia, observations and interviews revealed complaints of not being treated with dignity and respect, and reports from the resident's daughter indicated that staff were sometimes rough. Despite these behavioral concerns and allegations, there were no care plan interventions in place to address the resident's behaviors or false allegations, even though the care plan included other risks such as falls and communication deficits. The Director of Nursing acknowledged that these behaviors should have been care planned but were not. For another resident with multiple diagnoses including COPD, dementia, schizophrenia, CVA, diabetes, epilepsy, and heart failure, a plan of care was initiated to review functional abilities, but no interventions were included. Additionally, there was no care plan in place for limited range of motion until after an interview with the DON. The facility only had a partial restorative program in place, limited to dining activities. Other residents with complex medical histories, such as those on hospice, with indwelling catheters, or at risk for elopement, also lacked care plans addressing key aspects of their care, such as safe smoking practices, oxygen therapy, dementia, communication deficits, and disease-specific interventions. Record reviews and staff interviews confirmed that care plans were either missing, incomplete, or not updated to reflect the residents' current needs and conditions. The DON acknowledged that the care plans did not directly address the residents' care needs, resulting in a failure to provide a comprehensive care plan process for six out of twenty-one residents reviewed.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for a resident who was unable to perform these tasks independently. Multiple observations over several days revealed the resident in various states of poor hygiene and unkempt appearance, including tangled and messy hair, food particles in her lap and on her clothing, and stained, unclean shirts. The resident was also repeatedly observed with a thick yellowish substance around her teeth and gum line, indicating a lack of oral care. At times, her clothing was improperly positioned, such as a shirt pulled up to expose her abdomen, and her incontinent brief was visible above her pants. The resident was often seen slumped in her wheelchair or lying in bed, with little evidence of assistance provided to maintain her cleanliness or dignity. Record review indicated that the resident required moderate to maximum assistance with personal hygiene, showers, incontinent care, dressing, toileting, and transfers, as documented in her MDS assessment and care plan. The care plan specified that staff were to provide assistance with hygiene, mobility, dressing, grooming, oral care, and toileting needs. Despite these documented needs and interventions, the resident was consistently observed in a state that demonstrated a lack of appropriate care and assistance with activities of daily living.
Failure to Provide Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for a resident with a left hand contracture. Multiple observations over several days showed that the resident consistently did not have any splints or devices applied to her left hand to address the contracture, despite a care plan indicating a history of CVA and left side hemiparesis with a left hand contracture. Staff interviews revealed that the facility had not maintained a restorative program for some time, and the designated restorative aide was also required to perform regular CNA duties, limiting her ability to provide consistent restorative care, including ROM exercises and application of splints or devices. Record review indicated that the resident had significant functional limitations and impairments to both upper and lower extremities, as documented in the MDS and therapy screenings. Although therapy discharge summaries recommended 24-hour care, there were no restorative or functional maintenance programs in place for the resident at the time of the deficiency. The lack of consistent application of splints or devices and absence of a restorative program contributed to the facility's failure to provide necessary care and services to address the resident's contracture and limited ROM.
Failure to Monitor AV Fistula for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a newly placed arteriovenous (AV) fistula required for dialysis. The resident reported that nursing staff did not touch, palpate, or assess the fistula. Medical record review showed the AV fistula was placed on 4/10/25, but there were no physician's orders to check the bruit and thrill until 5/7/25. Hospital discharge instructions specified that the fistula site should be checked daily to ensure the thrill remained the same. Documentation revealed that the thrill was only assessed by nursing staff on three occasions: 4/12/25, 4/13/25, and 4/20/25. The DON confirmed that there were no orders to monitor the bruit and thrill prior to 5/7/25, despite the need for ongoing assessment since the fistula was placed.
Failure to Provide Prescribed Medication for Hepatic Encephalopathy
Penalty
Summary
A deficiency occurred when a resident with hepatic encephalopathy and liver cirrhosis did not receive their prescribed rifaximin 550 mg twice daily on multiple occasions due to the medication not being available from the pharmacy. The medication administration record and progress notes documented missed doses on several specific dates. The package insert for rifaximin indicates its use in reducing the risk of overt hepatic encephalopathy recurrence, and the resident was admitted with this diagnosis. On one of the days following missed doses, the resident experienced a change in condition, including increased tremors, confusion, and a decline in self-care, which led to a transfer to an acute care hospital for altered mental status. Hospital records confirmed that the facility had been out of rifaximin for several days prior to the transfer. During an interview, the DON acknowledged the resident's increased confusion and emotional upset when not receiving liver medications and confirmed the pharmacy's practice of sending only a five-day supply due to the medication's high cost.
Failure to Document Pneumococcal Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that four out of six residents reviewed had received education and were offered the pneumococcal immunization. Upon review of the medical records for these residents, there was no evidence of education, consent, or declination regarding the pneumococcal vaccine. Both paper and electronic records were checked, and interviews with the ADON and DON confirmed that such documentation should be present if a resident declines the vaccine. However, the required forms could not be located for the affected residents. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine should be offered within 30 days unless contraindicated or previously administered. The policy also requires documentation of education and any refusal in the resident's medical record. The absence of this documentation for the four residents reviewed constitutes a failure to follow established procedures for immunization education and consent.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that five out of six residents reviewed had received education and were offered the COVID-19 immunization, as required by facility policy. Upon review of both paper and electronic medical records, there was missing documentation regarding education and consent or declination of the COVID-19 vaccine for these residents. Interviews with the ADON and DON confirmed that education and the offer of immunization should occur on admission, and that a signed declination form should be present if a resident refuses the vaccine. Despite attempts to locate the required forms, the facility was unable to provide documentation for the affected residents. The facility's admission packet specifies that all residents are to be educated and offered the COVID-19 vaccine, with a signature required to indicate acceptance or declination.
Insufficient Privacy Curtains Compromise Resident Visual Privacy
Penalty
Summary
During an observation of two resident rooms, it was found that the privacy curtains between the occupied beds were insufficient in width to provide full visual privacy. In one room, the curtain was measured and found to be approximately two feet too short, while in another room, the curtain was about eighteen inches too short. These findings were confirmed by both the Maintenance Director and the Administrator during the walkthrough. The Administrator acknowledged that each room is expected to be equipped to provide full visual privacy to each resident. Photographic evidence was obtained to document the deficiency.
Failure to Conduct Timely Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that employee performance reviews were completed every 12 months for one of the six sampled Certified Nursing Assistant (CNA) staff members, identified as Staff Member D. During an interview, Staff Member D was unable to recall when her last training on resident rights, abuse prevention, and working with cognitively impaired residents with difficult behaviors occurred. A review of her employee file revealed that she was hired on 10/20/22, but there were no records of any performance evaluations or training in responding to cognitively impaired residents with difficult behaviors prior to 10/30/24. The Director of Nursing (DON) confirmed that the performance evaluation and training for Staff Member D were only completed on 10/30/24, the day before the interview. The DON was unable to provide any documentation of previous training or evaluations for Staff Member D before this date. This indicates a lapse in the facility's adherence to the requirement for annual performance evaluations and training for staff members, particularly in handling cognitively impaired residents with difficult behaviors.
Failure to Promote Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to uphold the dignity and quality of life for several residents by not allowing them to wear their personal clothing, not providing enough clean clothes, and restricting movement at night. Specifically, four residents were not allowed to wear their own clothes, and two residents did not receive enough clean clothes. One resident was restricted from leaving his room at night, which he expressed was due to staff citing it as a fire hazard. Additionally, there were issues with the availability of incontinence care supplies, leading to a resident wearing the same pull-up since the previous evening. Observations revealed that one resident was found unclothed in her bed with a strong smell of urine in the room, and she expressed distress over not receiving assistance for bathing. Another resident was using soiled bed linens and had unsuccessfully requested clean sheets. Multiple residents were observed wearing gowns despite preferring their own clothes, and one resident reported that night shift staff were rude and unaccommodating. The Director of Nursing acknowledged the concerns and mentioned efforts to provide clothing to residents in need.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to provide adequate supplies of clean laundry in four out of five linen storage areas, affecting eight of the 32 residents sampled. This deficiency was observed through resident and staff interviews, as well as direct observations by the surveyor. Residents reported issues such as wearing soiled or inappropriate clothing, lack of bed linens, and prolonged use of the same clothing without being washed. For instance, one resident was found wearing a patient gown and expressed a preference for regular clothes, while another resident had been using the same sheets for several days without them being changed. Staff interviews revealed that the facility often experiences shortages in linen supplies, with CNAs describing the situation as "horrible" and noting that linen rooms are poorly stocked. The lack of fitted sheets and other essential linens was a recurring issue, with staff reporting that they sometimes have to wait until the end of the day shift to obtain necessary items. The surveyor's tour of the laundry rooms confirmed these shortages, with many shelves completely empty or minimally stocked with essential items like sheets, pillowcases, and gowns. The Maintenance Director, who oversees laundry services, acknowledged the shortage of linens and indicated that there was a stock of linens in plastic bags designated as emergency supplies. However, these were not being circulated for regular use. The director mentioned that he had ordered more linens, but the order was pending approval from the administrator, who was currently on leave. This delay in processing orders further contributed to the deficiency in providing a safe, clean, and comfortable environment for the residents.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for several residents, as required by their grievance policy. From May to July 2024, seven out of ten grievances sampled were not properly documented or investigated. Specific grievances included a resident reporting a night nurse's inappropriate behavior, another resident complaining about staff refusing to heat water, and a resident lacking clothes and being unable to eat in the dining hall. Additionally, a family member reported issues with medication administration and incontinence care for two residents. None of these grievances had documented investigations or resolutions. Resident #16 reported a grievance about neglectful behavior by a CNA, which was not documented or investigated. The resident provided text messages with the DON as evidence of the grievance. The DON acknowledged awareness of the grievance but stated that the grievance was never filed by the weekend supervisor. The facility's grievance policy requires prompt resolution and documentation of grievances, which was not adhered to in these cases. The Social Services Director responsible for handling grievances was terminated for failing to perform these duties.
Inadequate Resident Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely assistance to residents in performing activities of daily living, including oral care, nail care, podiatry care, and general hygiene. Observations and interviews revealed that multiple residents were left in soiled conditions, with strong odors of urine present in their rooms, indicating a lack of adequate incontinence care. Residents reported not receiving regular baths or showers, with some unable to recall their last bath. Additionally, residents expressed frustration over the lack of assistance with dressing, transfers, and other personal hygiene tasks. Resident #6 was found unclothed in bed with long toenails and a strong smell of urine in the room. She expressed distress over not receiving help with bathing and nail care. Resident #1 was observed with dry, cracked lips, long fingernails with debris, and long toenails, indicating neglect in oral and nail care. He reported not being assisted out of bed frequently and had only received oral hygiene assistance on a few occasions over several weeks. Other residents, such as Resident #8, reported falls and a lack of assistance during the night, leading to increased pain and difficulty in performing daily tasks. Staff interviews confirmed that the facility was experiencing staffing shortages, particularly on evening and night shifts, which impacted the ability to provide adequate care. Certified Nursing Assistants (CNAs) and Patient Care Assistants (PCAs) reported being overwhelmed with the number of residents they were responsible for, leading to missed care tasks such as turning residents, providing showers, and changing linens. The facility's reliance on PCAs, who are not yet certified, further exacerbated the issue, as they were unable to perform all necessary care tasks independently.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the basic needs of residents, as evidenced by observations, resident interviews, staff interviews, and record reviews. Residents reported inadequate assistance with daily living activities, such as bathing, dressing, and oral hygiene. Many residents were found in unsanitary conditions, with long nails, soiled linens, and strong odors of urine in their rooms. The lack of staff resulted in residents not receiving timely assistance, leading to unmet care needs and compromised hygiene. Several residents expressed dissatisfaction with the care provided, citing long wait times for assistance, missed showers, and infrequent checks by staff. Some residents reported incidents of neglect, such as being left in soiled briefs for extended periods and not receiving help with transfers or mobility. The facility's staffing shortages were particularly pronounced during evening and night shifts, with insufficient numbers of CNAs and an over-reliance on less experienced PCAs, who were unable to perform all necessary care tasks independently. Staff interviews corroborated the residents' accounts, highlighting the challenges faced due to inadequate staffing levels. CNAs and nurses reported being overwhelmed by the high acuity of residents and the demands of enhanced supervision for certain individuals. The facility's inability to maintain adequate staffing levels resulted in residents not being repositioned, bathed, or provided with necessary care in a timely manner, contributing to the overall deficiency in meeting residents' care needs.
Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required wound care. The resident, who had been admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, hypertension, and chronic kidney disease, had a physician's order for wound care on the right scapula. This order, dated 5/30/24, specified cleansing the open area with wound cleanser and applying Duoderm every three nights and as needed. However, a review of the resident's most recent care plan, dated 6/6/24, revealed that it did not include any goals or interventions related to wound care, despite the resident having wounds prior to that date. An interview with a Registered Nurse and the facility's MDS coordinator confirmed that the resident should have been care planned for wounds during the most recent review. The facility's policy on comprehensive care plans, dated 9/1/2022, requires that each resident's care plan includes measurable objectives and timetables to meet their medical, nursing, mental, and psychological needs, and identifies the professional services responsible for each element of care. This policy was not adhered to in the case of the resident in question.
Failure to Obtain Laboratory Results for a Resident
Penalty
Summary
The facility failed to obtain laboratory results for a resident who was sampled for blood testing. A physician ordered laboratory tests for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and Hemoglobin A1c on 7/22/24. The Treatment Administration Record (TAR) indicated that the blood sample collection was completed on the same date. However, upon review of the resident's medical records, no laboratory results were found on file. The Director of Nursing (DON) requested the results, but they were not provided. A Registered Nurse (RN) confirmed the absence of lab results despite the physician's order and the documentation indicating the collection was completed.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Port Saint Joe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Emerald Shores | 29.8 mi | ★★★★★ | 0 | 0 |
| Clifford Chester Sims State Veterans Nursing Home | 30.4 mi | ★★★★★ | 0 | 0 |
| Community Health And Rehabilitation Center | 33.5 mi | ★★★★★ | 5 | 0 |
| St Andrews Bay Skilled Nursing And Rehabilitation | 33.9 mi | ★★★★★ | 3 | 0 |
| Pruitthealth - Panama City | 35 mi | ★★★★★ | 1 | 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.