Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Vero Beach Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
A resident with ESRD, cirrhosis, weakness, and urinary issues reported being left in a soiled brief because CNAs said they could not change him during meals, and he described rude responses when he used his call light overnight after spilling urine on himself and the bed. Staff said they were trained not to provide care during mealtimes, with the RN/unit manager and CNAs stating they waited until trays were delivered or picked up before changing residents.
Undated informed consents for psychotropic medications: A resident with dementia, bipolar disorder, major depressive disorder, and moderate cognitive impairment had orders for lithium, sertraline, and Nuedexta. The chart also contained five psychoactive medication consent forms for Seroquel XR, Keppra, Nuedexta, sertraline, and lithium, each signed by two staff members and the resident representative, but none included a date. The DON confirmed the missing dates.
Failure to provide ordered side rails for a resident with mild L hand contracture and ataxia. The resident was cognitively intact, had a side rail eval documenting benefit from bilateral side rails for bed mobility, and had an order for side rails as an enabler; however, observations showed the resident in bed with no side rails in place. The DON confirmed the resident was deemed appropriate and had requested the rails during a facility-wide audit, but they were not provided.
Unsafe and Unhomelike Room Conditions: Multiple resident rooms had bathroom emergency pull cords wrapped around grab bars, missing paper towels, and one room had a nonworking light bulb. In one room, a resident could not reach the bed light pull cord because it was too short, and the light could only be turned on by a wall switch near the door. Facility leadership acknowledged the issues during the tour.
A resident admitted with ESRD and dependence on HD did not have physician orders in place for immediate dialysis care at admission. The hospital transfer paperwork showed a standing M/W/F HD schedule and early chair time, but the facility did not have dialysis orders until after admission, and the resident missed the first scheduled treatment. Staff interviews showed the Admissions Director did not ask about special treatments, an LPN could not find dialysis paperwork and did not contact the physician, and the RN UM learned of the issue later but did not notify the physician. The dialysis center confirmed the resident had a chair time but had not been notified of the discharge until after the scheduled time had passed.
Inaccurate MDS coding affected three residents. One resident with dementia, anxiety, and depression received Seroquel during the look-back period, but the MDS coded antipsychotic use as no. Another resident with a left-hand contracture and ataxia was coded as having no UE impairment despite a physician order for a hand orthosis and confirmation that the hand was contracted. A third resident with a colostomy was observed with the ostomy, but the MDS coded no colostomy.
A resident receiving hospice services had missing documentation for required HHA and skilled nursing visits during the hospice recertification period, and the DON could not produce the ordered visit records. Multiple residents also had medications administered hours late, including BP meds, COPD meds, anticoagulants, pain meds, and psychotropics; residents reported their meds were routinely late. In addition, two residents had physician-ordered BP hold parameters ignored, with midodrine and metoprolol given when BP readings were outside the ordered limits or when no BP was documented.
Catheter Care and Perineal Hygiene Deficiencies: The facility failed to provide proper catheter care and perineal cleansing for multiple residents. One resident with a suprapubic catheter had the drainage spigot touching the floor and an unsecured tube, another resident had no documented catheter care after Foley insertion, and a third resident with urinary incontinence and a UTI was observed with red, excoriated skin while a CNA cleaned the perineal area back to front instead of front to back.
Dirty Oxygen Filter Left Uncleaned: A resident with COPD and SOB was receiving continuous O2 at 2 L/min, but the oxygen concentrator filter was observed to be dust laden and remained dirty on repeat observation. The resident was unsure who cleaned the filter, the ADON believed Central Supply was responsible, and Central Supply staff acknowledged the filter had been missed and was dirty.
A resident with chronic pain, COPD, opioid dependence, and intact cognition did not receive prescribed oxycodone for breakthrough pain when the facility ran out of the medication. The MAR showed missed doses marked as medication on order from pharmacy, and the resident reported pain when the doses were unavailable. An LPN/Unit Manager stated the physician had not been contacted to renew the order before the supply was exhausted.
PTSD Triggers Not Documented in Care Plan: A resident with PTSD, depression, anxiety, and moderate cognitive impairment had a care plan that included general supportive interventions but did not identify his triggers. A psych note documented trauma related to war with triggers of loud noises and strangers, yet staff interviewed said they did not know the resident’s triggers, and the MDS Coordinator acknowledged the care plan did not document them.
Incomplete monitoring documentation for psychotropic medications. A resident with dementia, bipolar disorder, and major depressive disorder was ordered lithium, sertraline, and Nuedexta, with orders to document behaviors, non-pharmacologic interventions, and side effects each shift. The MAR showed behaviors such as aggression, agitation, compulsive actions, and resisting care, plus several shifts marked for side effects observed, but progress notes contained no related documentation. The DON confirmed the documentation was incomplete.
A resident was found self-administering multiple supplements stored at their bedside without an assessment or care plan by the interdisciplinary team, as required by facility policy. The DON confirmed the lack of assessment and documentation for self-administration, despite the resident's ongoing use of these supplements and the facility's awareness of the situation.
A resident who was cognitively intact and required assistance with ADLs did not consistently receive showers as preferred, despite an updated shower schedule and previous grievances. Documentation showed missed or undocumented showers, and there was no evidence of resident refusal as required by policy, resulting in a failure to honor the resident's right to self-determination regarding bathing.
The facility failed to ensure timely skin assessments and medication administration for multiple residents. One resident with complex medical needs reported new skin issues that were not documented or communicated to the physician. Another resident experienced delays in receiving medications, missed showers, and unmet personal care preferences, with an LPN pre-signing medications before administration. A third resident reported ongoing late medication administration, with both morning and afternoon doses given hours after the scheduled time. These deficiencies occurred despite facility policy requiring medications to be given within one hour of the prescribed time.
A resident was found to have multiple bottles of pills and liquid supplements, such as MCT oil and testosterone boosters, stored unsecured on a bedside nightstand. The resident reported daily use and self-storage of these items, and the DON confirmed there was no assessment for self-administration and that bedside storage was not permitted.
A resident with cerebral palsy and contractures was found to have an unassessed wound on the right foot during a surveyor's observation. The wound care nurse and other staff were unaware of the wound, and erroneous measurements were documented. The facility failed to identify the wound during a skin check assessment, leading to a deficiency in care.
The facility failed to prevent and manage pressure ulcers for two residents. One resident experienced inadequate wound care due to improper procedures and lack of pain assessment, while another developed pressure wounds due to insufficient preventative measures and documentation. The staff did not adhere to care plans or implement necessary interventions to prevent and treat pressure ulcers effectively.
The facility failed to prevent and properly assess pressure ulcers for two residents. One resident developed ulcers on the heels due to a lack of preventative measures, and the treatment was delayed. Another resident had an unassessed ulcer on the right foot, which was only discovered during a surveyor's visit. The facility did not follow proper procedures, resulting in inadequate care and documentation.
The facility was found deficient in maintaining a clean and homelike environment, with issues such as sharp hooks, debris accumulation, and disrepair in multiple rooms. The Maintenance Director acknowledged these concerns during an environmental tour.
The facility failed to provide sufficient staffing, resulting in multiple falls, persistent odors, and inadequate personal care. Residents and families reported significant delays in call light responses, especially during night shifts. An LPN confirmed staffing shortages, leading to unattended treatments and compromised resident safety.
The facility failed to maintain food safety and sanitation standards, with issues such as unsecured sinks, improperly stored utensils, peeling paint, and debris on kitchen equipment. Raw beef was stored above tuna salad, and a dietary aide improperly dried trays. These deficiencies were acknowledged by the dietary management staff.
A facility failed to report a rash outbreak, potentially scabies, to the Florida DOH and did not ensure all affected residents received proper treatment. Additionally, a CNA did not follow Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, indicating a lack of adherence to infection control protocols.
The facility failed to maintain a safe and sanitary environment in common areas across four units, with issues such as dust and mold-like substances in air vents, water damage, and debris accumulation. The Maintenance Director acknowledged these concerns during an environmental tour.
A resident with Chronic Systolic Congestive Heart Failure and Severe Morbid Obesity was unable to obtain a recliner to elevate his legs, despite repeated requests and medical necessity. The facility did not provide a recliner, expecting the resident to purchase one himself, which he could not do due to financial constraints. A temporary solution was found when a staff member provided a torn recliner from the maintenance area, leading to an improvement in the resident's condition.
Residents in the facility expressed ongoing dissatisfaction with the food quality, describing it as repetitive and poorly cooked. Despite repeated complaints to the Dietary Manager and Activities Director, these grievances were not adequately documented or resolved. The disconnect between resident feedback and staff response highlights a deficiency in the facility's grievance resolution process.
A resident with severe cognitive impairment and a history of falls was found to be restrained by a seatbelt in a companion chair, contrary to the facility's restraint-free policy. Despite the facility's policy, the seatbelt was used, and the resident was unable to remove it independently. Family members expressed concerns about safety and staffing, and staff confirmed the unauthorized use of the restraint, which was provided by Hospice services.
The facility failed to accurately assess two residents, one with visual impairment and another regarding antianxiety medication use. A resident, legally blind, was documented as having adequate vision in MDS assessments, while another was incorrectly recorded as receiving antianxiety medication without supporting MAR evidence. These inaccuracies were confirmed through staff interviews and record reviews.
The facility failed to develop and implement adequate care plans for two residents, one with a catheter and another with vision impairment. A resident with severe cognitive impairment was observed with an improperly placed catheter bag, and the care plan did not address his behavior of manipulating the catheter. Another resident, who is legally blind, had a care plan inaccurately reflecting his vision status, which was only revised after surveyor observation. These deficiencies highlight the facility's failure to maintain accurate and comprehensive care plans.
The facility failed to update care plans for two residents, one with aggressive behavior and another with a discontinued fluid restriction. Despite discussions, the care plan for a resident involved in altercations lacked documentation of aggression. Another resident's care plan inaccurately included a fluid restriction order that was no longer in place. The DON was unable to explain these discrepancies.
A resident with medically complex conditions and an ADL self-care deficit was left in wet adult depends after a CNA refused to change her, citing it was only urine. The resident, who was cognitively intact and expressed feelings of depression, required substantial assistance with toileting and hygiene. Despite requesting to be changed and transferred back to her wheelchair, the CNA left her in bed, highlighting a deficiency in meeting the resident's care needs.
The facility failed to coordinate hospice care and services for two residents, resulting in undocumented hospice and oxygen orders for one resident and lack of an offloading boot and hospice documentation for another. Staff interviews revealed a lack of awareness and communication regarding necessary care and equipment.
A resident with a history of falls experienced multiple incidents without adequate updates to their care plan or supervision. Despite several falls resulting in injuries, the facility's IDT often failed to implement new interventions. Interviews revealed concerns about inadequate staffing in the memory care unit, contributing to the inability to prevent falls effectively.
The facility failed to secure medication storage on two units, leaving medication and treatment carts unlocked and unattended. On the memory care unit, an LPN left a medication cart unsecured for over two hours, with cognitively impaired residents present. In another instance, a medication cart was found unattended with unsecured ointments, and a treatment cart was left unlocked in a common area with residents present.
The facility failed to maintain complete medical records for three residents, resulting in missing documentation of podiatry services, orthopedic follow-up, and psychological notes. A resident reported not seeing a podiatrist, and another had no record of an orthopedic follow-up. Additionally, a resident with behavioral issues had no psychological notes since the previous year. Staff interviews revealed lapses in communication and documentation processes.
The facility failed to properly explain arbitration agreements to two residents with intact cognition, resulting in signatures being obtained without understanding. The new Admissions Director, who was untrained, did not use the electronic signature process or provide copies of the agreements. The facility's records inaccurately reflected agreement to arbitration.
The facility failed to maintain a functioning call system for a resident and did not ensure the call light was accessible for another. A resident with intact cognition was unable to signal for help due to a non-functioning call system, confirmed by an LPN. Another resident could not reach the call light as it was improperly placed, with the cord wrapped around the bedrail and the button under the bed, as noted by the Environmental Services Director.
The facility did not ensure timely posting of nurse staffing information on four out of five days during a survey. The required information was not posted in the lobby area as expected, and there was confusion among staff about who was responsible for this task. The Administrator indicated that the night supervisor and receptionist were responsible, but this was not clearly communicated.
The facility failed to maintain a clean and safe environment, with issues such as torn wheelchair armrests, dirty floors, and unclean toilets. Residents reported longstanding cleanliness problems, including a pill on the floor for a month and dirty windows. Despite claims of cleaning, the surveyor found persistent issues, which the Housekeeping Supervisor acknowledged but could not explain.
A facility failed to follow physician orders for blood pressure medication and wound vac care for two residents. Medications were administered despite low systolic blood pressure, and wound vac care was not documented or consistently provided due to staffing issues and lack of training. The DON confirmed the deficiencies.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Provide Dignified Care During Mealtimes and Overnight Assistance
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner. Resident #171 was admitted with diagnoses including acute kidney failure, alcoholic cirrhosis of the liver with ascites, end stage renal disease with dependence on renal dialysis, muscle weakness, muscle wasting and atrophy, benign prostatic hyperplasia with lower urinary tract symptoms, and lack of coordination. During interview, the resident stated that when he soiled his brief and asked to be changed, CNAs told him they could not change him during breakfast, so he remained in a dirty brief until they could do so. He also reported that when he pressed his call light overnight after spilling urine from his urinal onto the bed and himself, a CNA responded with a nasty attitude, changed only part of his clothing, and returned with an attitude when he called again because his gown remained wet and he was freezing. Staff interviews showed that the CNA staff believed they were not allowed to provide resident care during mealtimes. A CNA stated residents could not be changed during mealtimes because of infection control, and an RN/unit manager stated CNAs were not allowed to go into rooms to change residents until meals were delivered. Another CNA stated staff were trained not to do care during meals and had to wait until trays were delivered and picked up, though she said she might provide care in an emergency. The grievance documented the resident’s report that overnight staff questioned why his light was on, turned it off, said they would be right back, and later told him they had to start rounds over again after he spilled urine and needed assistance.
Undated informed consents for psychotropic medications
Penalty
Summary
The facility failed to obtain completed informed consent forms with dates for psychotropic medications prescribed to Resident #9. Review of the facility’s policy stated that consent for medications, including psychotropic medications, is included in the consent to treat, and documentation for procedures and treatments must include care-specific details, including the date and time provided. Resident #9 was admitted with diagnoses including generalized anxiety disorder, cognitive communication deficit, dementia, unspecified mood disorder, bipolar disorder, and major depressive disorder, and had a BIMS score of 10 indicating moderate cognitive impairment. Record review showed physician orders for Lithium Carbonate 300 mg twice daily, Zoloft 100 mg daily, and Nuedexta 20-10 mg daily. The psychoactive medication informed consent forms on file included five separate consents for Seroquel XR 150 mg, Keppra 1,000 mg, Nuedexta 20-10 mg, Zoloft 100 mg, and Lithium Carbonate 300 mg. Each form documented verbal consent from the resident representative and signatures from two staff members, but none of the five forms had a date. During interview, the DON confirmed there were no dates on the informed consents and stated they should have a date.
Failure to Provide Ordered Side Rails
Penalty
Summary
Reasonably accommodating the needs and preferences of each resident was not ensured for Resident #42 when bedside side rails were not in place despite a physician order and a completed side rail evaluation. The resident was admitted with diagnoses including mild left-hand contracture and ataxia, had a BIMS score of 15 indicating cognitive intactness, and had an order dated 01/07/26 for bilateral side rails as an enabler for bed mobility. The facility's side rail evaluation dated 01/30/26 documented that the resident would benefit from both side rails to promote independence for transferring and movement in bed, and that the resident understood the risks and benefits and consented to their use. The Side Rail Consent form dated 06/11/25 had no signature, and during observations on 02/17/26 and 02/18/26 the resident was seen in bed with no side rails in place. During interview, the DON stated PT/OT would screen residents for appropriateness, consent would be obtained if appropriate, and an order would be placed; she confirmed the resident had been deemed appropriate, had an order for side rails since 01/07/26, and that the resident had requested them during a facility-wide side rail audit in January but did not receive them.
Unsafe and Unhomelike Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in 5 of 14 resident rooms on the [NAME] Unit, affecting residents in rooms 107, 112, 115, 116, and 117. Observations identified emergency pull cords in multiple bathrooms wrapped around grab bars instead of hanging freely, and several bathrooms without paper towels. In one room, a bathroom had no paper towels and the emergency pull cord remained wrapped around the grab bar across repeated observations. In another room, one light bulb was not working, and in another room the bathroom had no paper towels while the emergency pull cord was also wrapped around the grab bar. In room 112, the light above the bed for Resident #68 did not work unless the wall switch by the door was activated, and the pull cord from the light behind the resident was only about 8 inches long, which the resident said she could not reach. During interview, Resident #68 stated she could not get out of bed without assistance and said it would sometimes be nice to turn on the light herself. During the facility tour, the Administrator, Director of Maintenance, Director of Housekeeping, and Regional Plant Operations acknowledged that some room light switches controlled the bed lights, that some pull cords were too short for residents to reach, that some bathrooms did not have paper towels, and that some emergency pull cords were wrapped around grab bars and should have been hanging freely.
Missing Dialysis Orders at Admission
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident’s immediate care at the time of admission, specifically for dialysis. The resident was admitted with diagnoses including acute kidney failure, alcoholic cirrhosis of the liver with ascites, ESRD, dependence on renal dialysis, muscle weakness, muscle wasting and atrophy, benign prostatic hyperplasia with lower urinary tract symptoms, and lack of coordination. The resident’s records showed he was alert, oriented, and able to follow directions, and the hospital transfer form documented dialysis on Monday, Wednesday, and Friday with an early morning chair time. The admission record did not contain dialysis orders until after the resident had already been admitted, and the resident missed the scheduled dialysis treatment on the first Monday after admission. The physician orders later included hemodialysis three times weekly at a named dialysis center, transport arrangements, dialysis access precautions, meal/snack instructions before dialysis, and monitoring of the dialysis access site. The report states that there were no dialysis orders until after admission, and the resident was upset that dialysis had not been done as expected. Staff interviews showed that the admission process did not identify or secure the resident’s dialysis needs at the time of admission. The Admissions/Marketing Director stated the hospital did not inform her that the resident was receiving dialysis and she did not ask about special treatments. The LPN stated he could not find dialysis paperwork or orders and did not contact the physician. The RN Unit Manager stated she learned of the missing dialysis orders after a text message, contacted Admissions, and later obtained the orders, but she did not notify the physician. The Medical Director stated he was unaware whether the resident needed dialysis, and the dialysis center confirmed the resident had a standing chair time but had not been notified of the discharge until after the scheduled treatment time had passed.
Inaccurate MDS Coding for Medications, Mobility, and Colostomy Status
Penalty
Summary
The facility failed to accurately code antipsychotic medication use for Resident #82 on the Quarterly MDS assessment with an ARD of 12/04/25. The resident was admitted with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression. The MDS coded antipsychotic medication use as No in Section N0410A, but the December 2025 MAR showed the resident received Seroquel (quetiapine) 25 mg by mouth twice daily for brief psychosis/mood stabilization from 12/01/25 through 12/05/25. During a side-by-side review, the MDS Coordinator confirmed the medication was administered during the look-back period and agreed the assessment was coded inaccurately. The facility also failed to accurately code mobility status for Resident #42 and the presence of a colostomy for Resident #153. Resident #42 had diagnoses including mild left-hand contracture and ataxia, and the current MDS dated 02/04/26 documented no impairment to the upper extremities despite a physician order for a left-hand Blue Carrot orthosis in the mornings and after ADLs as tolerated. During record review, the MDS Coordinator confirmed the resident's left hand was contracted. Resident #153 had a colostomy as of 10/30/24, and the resident showed it to the surveyor during observation; however, the Quarterly MDS documented no colostomy. The MDS Coordinator stated she knew the resident had a colostomy and agreed with the finding.
Missed Hospice Services, Late Medication Administration, and Failure to Follow BP Parameters
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for a resident receiving hospice services. The resident had significant cognitive impairment with a BIMS score of 00 and was receiving palliative and/or hospice services under a recertification period from 11/17/25 through 02/14/26. The hospice agreement required skilled nursing and home health aide services according to the hospice plan, but the record lacked evidence of multiple required HHA visits during several weeks and lacked evidence of weekly skilled nursing visits. During an interview and record review, the DON acknowledged the absence of documented hospice visits in the facility record, and the hospice nurse stated she would search for the documentation, but the requested documents were not provided. The facility also failed to ensure medications were administered within the ordered time frame for multiple residents. For one resident, the MAR showed several medications given well beyond the one-hour window, including metoprolol, fluticasone-salmeterol, aspirin, furosemide, prednisone, lactulose, topiramate, rosuvastatin, gabapentin, amitriptyline, metformin, and others, with some doses delayed by several hours. The resident stated her medications are always late. For another resident with COPD, diabetes, atrial fibrillation, hyperlipidemia, depression, and heart failure, the MAR showed repeated late administration of trazodone, fluticasone-salmeterol, amiodarone, tizanidine, Eliquis, rosuvastatin, buspirone, desvenlafaxine, vitamins, probiotics, metformin, guaifenesin, Pepcid, pantoprazole, roflumilast, metoprolol, and morphine. The resident stated she was supposed to receive morning blood pressure medication but did not receive it until late morning and reported that her BP was high when checked before receiving it. A third resident’s MAR showed late administration of Flomax, trazodone, midodrine, enoxaparin, methocarbamol, and Tylenol, including nighttime medications not given until early morning and evening medications not given until late at night. The resident stated her nighttime medications were not brought until 2:00 AM and denied refusing them, despite progress notes documenting refusal. Staff interviews confirmed that medications should be given within one hour before or after the scheduled time and acknowledged that medications were late on several occasions. The facility also failed to follow physician-ordered blood pressure parameters for two residents receiving antihypertensive or blood pressure-supporting medications. One resident had orders for midodrine to be held if systolic BP was greater than 120, but the MAR showed doses given when the documented BP was above the ordered parameter or when no BP reading was documented at the scheduled time. Another resident had an order for metoprolol to be held if systolic BP was less than 120, yet the MAR showed doses given when BP readings were below 120 and on one occasion with no documented BP reading. The DON agreed with the findings for both residents.
Catheter Care and Perineal Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure appropriate catheter care and infection prevention for residents with indwelling urinary catheters and failed to provide proper perineal care for a resident with urinary incontinence. The facility policy stated that routine hygiene and care of the peri area is appropriate when providing incontinence care and bathing, and that the drainage spigot is not to touch the floor. The report identified deficiencies involving three residents related to catheter care, catheter maintenance, and perineal cleansing technique. Resident #68 had a suprapubic urinary catheter ordered to be monitored every shift, and the resident stated she had urinary tract infections quite frequently. During observations, the catheter drainage bag was suspended from the bed frame but the drain was out of the holder and touching the floor. A nurse later acknowledged the unsecured drainage tube and that the drain was out of the holder. Two CNAs stated the drainage tube should be secured and the drain should remain in the holder, and one stated leaving it out could catch bacteria. Resident #14 had an indwelling urinary catheter inserted for urinary retention, but there was no active order for catheter care and no documentation of catheter care in the MAR, TAR, or progress notes for the month reviewed. The ADON/IP acknowledged the resident had an indwelling urinary catheter since the insertion order and that no catheter care had been documented. Resident #41 was admitted with ESBL of the urine, had a BIMS score of 13, and was always incontinent of urine with a UTI in the past 30 days. During observed personal care, the resident’s groin and buttocks were red and excoriated, and the CNA cleaned the buttock and anal area from back to front instead of front to back as required by the competency checklist.
Dirty Oxygen Filter Left Uncleaned
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to clean the oxygen filter for Resident #77. The resident was admitted with diagnoses including COPD and shortness of breath, had a BIMS score of 15 indicating cognitive intactness, and was receiving continuous oxygen at 2 liters per minute for shortness of breath. The current physician orders directed staff to change the oxygen tubing weekly, but there were no orders related to cleaning the oxygen canister filter. The care plan identified the resident as at risk for altered respiratory status and difficulty breathing related to episodes of shortness of breath and pneumonia. During observation, the resident was lying in bed with oxygen running at 2 liters per minute and stated the tubing had been changed that day. The oxygen filter on the back of the concentrator was observed to be dust laden and gray instead of black, and it remained in the same dirty condition on a later observation. The resident was unsure whether anyone cleaned or changed the filter. During interview, the ADON stated she thought Central Supply was responsible for cleaning the filters, and the Central Supply staff person stated she was responsible and washed the filters weekly, but also said she often got distracted by other tasks. She acknowledged the filter for Resident #77 had been missed, was dirty, and she was unsure exactly what happened.
Missed opioid doses for resident with chronic pain
Penalty
Summary
The facility failed to provide pain management for one resident when prescribed oxycodone was not administered as ordered for breakthrough pain. Resident #66 was admitted with diagnoses including Alcohol Dependence, COPD, Opioid Dependence, Chronic Pain Syndrome, pain in both knees, and low back pain, and the most recent MDS documented a BIMS score of 15, indicating intact cognition. A physician order dated 12/02/25 directed Oxycodone HCl 5 mg, 1 tablet by mouth every 4 hours for breakthrough pain, but the MAR for 02/16/26 and 02/17/26 showed missing doses coded as medication on order from pharmacy. The record showed that after the third scheduled 5 mg oxycodone dose was not given, the resident’s pain level was documented as 5/10 on the night shift of 02/16/26. The resident stated the facility ran out of his pain medication and reported having pain when the medication was unavailable. Staff D, LPN and manager for Unit 1, stated that the nurse typically assigned to the resident and the manager for Unit 2 had ended employment on 02/13/26, that nobody had contacted the pain management doctor to renew the medication order until she was advised, and that the Medbank machine would not provide the code for narcotic medication if the prescription was not current. Staff D confirmed the facility should have contacted the physician before running out of the pain medication.
PTSD Triggers Not Documented in Care Plan
Penalty
Summary
The facility failed to ensure that a resident with PTSD had triggers identified and incorporated into the care plan. Resident #7 was admitted and later readmitted with diagnoses including PTSD, major depressive disorder, generalized anxiety, insomnia, type II diabetes, coronary artery disease, alcoholic cardiomyopathy, migraines, muscle weakness, and COPD. The resident’s MDS 5-day assessment documented a BIMS score of 10, indicating moderate cognitive impairment. The care plan noted that the resident had experienced a traumatic event affecting emotional health and included interventions such as psychiatric/psychological referral as needed, notifying the MD/designee of behavior changes, encouraging activities of choice, family/friend contact, expression of feelings, providing a quiet and non-threatening environment, and respecting space and privacy, but it did not identify any triggers. A psychiatric note documented a history of PTSD with nightmares, flashbacks, hypervigilance, and significant distress and functional impairment, and listed trauma as war with triggers of loud noises and strangers. The resident’s admission record and social service assessments did not document PTSD initially, and the social service trauma screen documented no PTSD and no military experience as baseline. During interview, the resident was unable to verbalize his triggers but stated he had been in the military. Staff interviewed about the resident’s PTSD stated they knew he had PTSD but did not know his triggers, and the MDS Coordinator acknowledged that triggers should be documented in the care plan but were not, noting there was no Social Service Director at the time.
Incomplete Monitoring Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for a resident receiving psychotropic medications. Resident #9 had diagnoses including generalized anxiety disorder, cognitive communication deficit, dementia, unspecified mood disorder, bipolar disorder, and major depressive disorder, and the MDS documented moderate cognitive impairment with a BIMS score of 10. Physician orders included lithium carbonate 300 mg twice daily, sertraline 100 mg daily, and Nuedexta 20-10 mg daily, along with orders to document behaviors, non-pharmacologic interventions, and psychotropic medication side effects each shift. Review of the February 2026 MAR showed multiple entries documenting behaviors such as aggression, agitation, compulsive actions, and avoidance/resisting care, as well as several shifts marked with an 'N' for side effects observed. However, review of progress notes from 02/01/26 through 02/10/26 found no documentation related to the recorded behaviors or side effects. During interview, the DON confirmed that the documentation for behaviors and side effects for Resident #9 was incomplete.
Failure to Assess and Plan for Resident Self-Administration of Medication
Penalty
Summary
A resident was observed with approximately ten bottles of pills and liquid supplements stored openly on their nightstand, including MCT oil, Nugenix Thermo X, weight loss probiotics, veggie capsules, testosterone boosters, and fruit dietary supplements. The bottles were open, and the resident reported self-administering these supplements daily due to dissatisfaction with the facility's food and a personal goal to lose weight. During the observation, the resident informed the LPN about the supplements after receiving their scheduled medication from the nurse. Interviews with facility staff, including the Director of Nursing, confirmed that the resident had not been assessed by the interdisciplinary team for self-administration of medication, nor was there a care plan in place for this practice. Review of the clinical record showed no documentation of such an assessment or care plan, despite facility policy requiring physician and care team approval for residents to self-administer medications. The facility was aware that residents were not permitted to store medications at their bedside without proper assessment and planning.
Failure to Honor Resident's Bathing Preferences and Support Self-Determination
Penalty
Summary
A deficiency was identified when a resident's right to self-determination and choice regarding bathing preferences was not honored. The resident, who is cognitively intact with a BIMS score of 15, reported not receiving a shower for approximately three weeks, despite expressing a preference for showers over bed baths. The resident also stated that his requests for specific types of incontinence briefs and linen changes were not consistently met, and that his leaking toilet had not been addressed. Staff interviews confirmed that the resident required assistance with activities of daily living (ADLs) and that there were inconsistencies in providing showers according to the resident's preferences and the facility's updated shower schedule. Review of facility documentation, including the resident's care plan, Kardex, and ADL task sheets, revealed that the resident was scheduled to receive showers on Monday, Wednesday, and Friday during the 7AM-3PM shift. However, records for April and May showed multiple instances where showers were not documented, and the resident often received sponge baths or full baths instead. There was also a lack of documentation indicating that the resident refused showers, as required by facility policy. The grievance log and Resident Council minutes indicated that the resident had previously raised concerns about not receiving showers as preferred, and the issue was marked as resolved after the shower schedule was updated, but subsequent documentation did not support consistent implementation of this schedule. Facility policy requires that all residents be offered and provided a shower unless they specifically request a bed bath, and any refusal must be documented with appropriate notifications. In this case, the lack of consistent documentation and failure to provide showers as scheduled demonstrated that the facility did not fully support or facilitate the resident's right to choose their preferred method of bathing, resulting in a deficiency.
Failure to Ensure Timely Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services related to timely skin assessments and medication administration for several residents. One resident, with a history of diabetes, cerebrovascular disease, chronic kidney disease, hypertension, and blindness in one eye, reported new, painful, and itchy skin lesions to the surveyor. Upon assessment, the LPN stated a dermatology consult would be obtained, but there was no documentation of the new skin issues, no evidence of physician notification, and no new treatment orders in the clinical record. The DON later confirmed that new skin issues should be documented and that an order for cortisone was obtained only after the surveyor's inquiry. Another resident expressed dissatisfaction with care, stating that medications had not been received, showers had been missed for weeks, linens were not changed, and personal preferences for incontinence products were not honored. The DON initially reported that medications had been administered, but the nurse was later observed preparing and administering the resident's medications, which had already been signed off as given in the electronic record. The nurse admitted to pre-pouring medications, signing them off before administration, and delaying medication administration due to taking a lunch break, with morning medications not completed until late morning or noon. A third resident, who had resigned as Resident Council President due to ongoing unresolved issues, reported persistent delays in medication administration, including a specific incident where morning medications were not received until after noon. The resident also noted that afternoon medications were given in the evening. The nurse confirmed that medication passes for the hall were routinely not completed until late morning or noon. The DON acknowledged the resident's complaint but had not initiated a grievance or addressed the ongoing late medication administration concerns. Facility policy requires medications to be administered within one hour of the prescribed time, which was not consistently followed.
Unsecured Storage of Medications and Supplements at Bedside
Penalty
Summary
Surveyors observed that a resident had approximately ten bottles of pills and liquid supplements, including MCT oil, Nugenix Thermo X, weight loss probiotics, veggie capsules, testosterone boosters, and fruit dietary supplements, stored unsecured on top of the bedside nightstand. These items were clearly visible upon entering the resident's side of the room. During interviews, the resident confirmed daily use of these supplements and acknowledged storing them on the nightstand. The DON confirmed that the resident had not been assessed for self-administration of medication and was aware that medications were not to be stored at the bedside.
Failure to Identify and Assess Resident's Wound
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess wounds for a resident with a history of cerebral palsy, malnutrition, and contractures. The deficiency was identified when a surveyor observed a wound care nurse performing treatment on the resident's left foot but failing to inspect the right foot, where an open wound was later discovered. The wound care nurse was unaware of the wound on the right foot, and erroneous measurements were documented once the wound was identified. Interviews with staff revealed a lack of awareness and documentation regarding the resident's right foot wound. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) assigned to the resident were both unaware of the wound, and the RN had failed to identify it during a skin check assessment conducted the day before the surveyor's observation. The facility's Director of Nursing (DON) confirmed that a facility-wide skin sweep had been conducted, but the wound on the resident's right foot was still not identified. The wound care provider later assessed the wound as a trauma wound, noting it required surgical debridement and specific treatments. The provider suggested the wound could have been caused by friction or trauma, possibly due to the resident's limited mobility and contractures. The investigation concluded that the facility failed to identify and properly assess the wound prior to surveyor intervention, leading to the deficiency.
Plan Of Correction
F684, Quality of Care (1) What corrective action(s) will be accomplished for those residents who found to have been affected by the deficient practice? On resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice, none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received and treatment initiated on. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. A quality review of current residents' skin was completed by the nurse practitioner/designee to ensure no new skin were noted and required treatment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. The Assistant Director of Nursing or designee-initiated education for the current licensed nurses on about Comprehensive Skin Assessment and Areas to monitor on the body that are Susceptible to. Newly hired nurses will receive education by the Assistant Director of Nursing or designee related to the following: about Comprehensive Skin Assessment and Areas to Monitor on the Body that are Susceptible to. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Assistant Director of Nursing/Designee to conduct weekly audits of resident's Skin Assessments 2x weekly for 8 weeks, then 1x weekly for 4 weeks, and then random audits x 1 week for 4 weeks to ensure compliance with Care identification and appropriate treatments provided. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers for two residents. For Resident #3, the Wound Care Nurse (WCN) did not follow proper procedures during wound care, including failing to perform hand hygiene after removing a dirty dressing and before cleansing the wound. The resident, who has cerebral palsy, malnutrition, and contractures, expressed pain during the procedure, indicating a lack of assessment of the resident's tolerance to the treatment. The care plan for Resident #3 included specific interventions for skin checks and the use of supportive devices, but these were not adequately followed during the observed wound care session. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure wounds. The resident was admitted for rehabilitation after a cervical fracture and initially had intact skin with no pressure wounds. However, the resident developed pressure wounds on the heels, which were not documented or staged in a timely manner. The WCN noted that the resident preferred to stay on their back due to a cervical collar, but there was no documentation of refusal to offload the heels or use preventative measures like offloading boots or skin prep before the wounds developed. The investigation revealed that the facility's staff were aware of the residents' conditions and preferences but failed to take appropriate actions to prevent and manage pressure ulcers. The lack of documentation and adherence to care plans contributed to the development and inadequate treatment of pressure wounds in both residents.
Plan Of Correction
F686, Treatment/Svc to prevent/ heal 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, no longer resides in the facility, discharged on. Resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice; none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received, and treatment initiated on. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A quality review of current residents' skin was completed by the nurse practitioner/designee on to ensure no new skin issues were noted and required treatment. Any issues identified were immediately corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. The Assistant Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of. Newly hired nurses will be educated on the components of Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of by the Assistant Director of Nursing/designee at orientation as part of the systematic changes. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The Assistant Director of Nursing/designee will conduct random audits of 5 residents to ensure that their treatment and services have been provided according to their Physician Orders, 2x a week for 4 weeks, then 1x a week for 4 weeks, and then monthly for 1 month to ensure compliance. The findings of these quality monitoring will be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met. F 686
Failure to Prevent and Assess Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess skin conditions for two residents. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure ulcers. The staff were aware that the resident preferred to stay in a certain position due to a device in use, but there was no documentation of the resident's refusal to offload his heels. The treatment to mitigate the pressure ulcers, including the use of skin prep, was initiated only after the first ulcer developed. For Resident #3, the facility failed to identify and properly assess a pressure ulcer on the resident's right foot prior to surveyor intervention. The wound care nurse (WCN) did not perform hygiene after removing a dirty dressing and before applying treatment, and the resident's tolerance to the treatment was not acknowledged. The WCN also failed to inspect the right foot, where an open wound was later discovered by the surveyor. The nurse had no knowledge of the wound, and the facility's documentation did not accurately reflect the resident's condition. The facility's failure to follow policies and procedures during treatment administration and to conduct thorough skin assessments resulted in the oversight of existing wounds. The Director of Nursing (DON) confirmed that a facility-wide skin sweep was conducted, but the right foot wound was still missed. The investigation determined that the facility did not adequately assess and document the residents' skin conditions, leading to deficiencies in care.
Plan Of Correction
N201: Right to Adequate and Appropriate Healthcare. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, no longer resides in the facility, discharged on. Resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice; none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received, and treatment initiated on. An order effective was created to provide off-loading; treatment to Resident #3. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Licensed Nursing staff will conduct weekly skin audits to monitor the residents for change in skin condition. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. On, the Assisted Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing of, with emphasis on providing treatment to ensure the healing of the. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Assistant Director of Nursing/designee will conduct random audits of 5 residents with to ensure that their treatment and services have been provided according to their Physician Orders, 2x a week for 4 weeks, then 1x a week for 4 weeks, and then monthly for 1 month to ensure compliance. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across multiple units and common areas, as observed during an environmental tour with the Maintenance Director. Specific deficiencies included sharp picture hanging hooks protruding from walls, accumulation of residue and debris on air conditioning units, and multiple instances of disrepair such as damaged walls, missing closet doors, unsecured outlets, and worn furniture. Additionally, there were several instances of uncleanliness, including stained privacy curtains, dirty floors, and stained bed linens. The tour also revealed issues such as mold-like substances on bathroom caulking, unsecured baseboards, and damaged blinds. The Maintenance Director acknowledged understanding of these concerns during the tour. These observations indicate a failure to provide adequate maintenance and housekeeping services, compromising the residents' right to a safe and comfortable living environment.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing, as evidenced by multiple incidents and complaints across various units. On one unit, a resident experienced eleven falls, and the facility did not follow its fall prevention policy. Additionally, a persistent stale urine odor was noted throughout the unit during the survey, indicating a lack of adequate cleaning and care. Another resident did not receive personal care or assistance out of bed when requested, highlighting a failure in providing necessary activities of daily living (ADL) care. The facility also failed to coordinate hospice care for two residents, as there was no evidence of care coordination, order implementation, or hospice documentation. Numerous residents and family members voiced complaints about delayed responses to call lights, with some residents waiting up to two hours for assistance. These delays were particularly problematic during the night shift, where residents reported issues such as double diapering and missed personal care. The Resident Council minutes also reflected ongoing concerns about delayed call light responses. Staff interviews further confirmed the staffing inadequacies, with an LPN acknowledging insufficient staffing on a memory care unit. This lack of staffing led to situations where residents were left unattended during treatments, such as a nebulizer treatment. The overall findings indicate a systemic issue with staffing levels, impacting the quality of care and safety of residents in the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food safety and sanitation standards during a kitchen inspection. Observations revealed several deficiencies, including unsecured hand washing sinks and baseboards, improperly stored utensils, and peeling floor paint. There was also an accumulation of debris on kitchen equipment such as the can opener and slicer, and damaged shelving and rusted areas were noted. Additionally, the air conditioning vents were dusty, and the oven mitts were torn and uncleanable. In the walk-in cooler, raw beef was improperly stored above prepared tuna salad, and the cooler door was damaged. Cleaned hotel pans were found stacked while still wet, and the hand sink near the ice machine was not functional. The floor throughout the food service area was also damaged. During a follow-up kitchen tour, a dietary aide was observed using a paper towel to dry trays before meals were placed on them, which were then transported to the units. This practice was acknowledged by the Dietary Manager, the Regional Certified Dietary Manager, and the dietary aide as a concern. These observations indicate a failure to adhere to professional standards for food safety and sanitation, as acknowledged by the facility's dietary management staff.
Infection Control Deficiencies in Rash Outbreak and EBP Implementation
Penalty
Summary
The facility failed to adhere to infection control standards during a rash outbreak on one of its units, affecting multiple residents. The outbreak, which involved symptoms consistent with scabies, was not reported to the Florida Department of Health (DOH) as required. Several residents were administered Ivermectin for dermatitis or scabies, but not all received the recommended second dose, and some roommates were not treated prophylactically. The Physician Assistant who ordered the medication was unaware that some residents did not receive the second dose and did not recall the specifics of the rashes treated. The Director of Nursing (DON) did not report the outbreak to the DOH, claiming unawareness of the requirement. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter. During an observation, a Certified Nursing Assistant (CNA) failed to don a gown while providing personal and catheter care, despite the policy requiring gowns and gloves for such procedures. The CNA admitted to not being informed about the necessity of wearing a gown, indicating a lack of proper training or communication regarding EBP protocols. The report highlights deficiencies in both the management of a potential scabies outbreak and the implementation of EBP for infection control. The facility's failure to report the outbreak and ensure proper treatment and precautions for affected residents demonstrates a significant lapse in infection prevention and control measures.
Environmental Deficiencies in Common Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and the public in the common areas across four of its five units. Observations revealed an accumulation of dust and mold-like substances in the air conditioning vents and ducts in multiple units, including the common and dining areas. Additionally, the shower room on the Canterbury unit had a large puddle of water on the floor, a running toilet, and damaged walls, while the soiled utility room had a damaged wall and a sink filled with standing dirty water. Further deficiencies were noted in the employee bathroom of one unit, where the wall and baseboard were damaged, and the wall at the handwashing sink was unfinished. The patio area had debris in the air conditioning vents, and the nurse's station restroom had an unsecured sink and a hole in the wall. Other issues included broken and oxidizing sink handles, holes in the walls around the nurse's station, and debris accumulation in pantries. The Maintenance Director acknowledged these concerns during an environmental tour.
Failure to Provide Recliner for Resident's Medical Needs
Penalty
Summary
The facility failed to honor a resident's choice to sleep in and utilize a reclining chair, which was necessary for his medical condition. The resident, who had multiple diagnoses including Chronic Systolic Congestive Heart Failure and Severe Morbid Obesity, required leg elevation to manage his symptoms. Despite his intact cognition, as indicated by a BIMS score of 15, the resident's repeated requests for a recliner were not fulfilled by the facility. The resident had been advised by his physician to elevate his legs as much as possible, yet he was unable to do so due to the lack of a recliner, which he had been trying to obtain since his admission. The resident's care plan documented his preference for a recliner to assist with sleeping and mobility, but the facility did not provide one. Interviews with the Director of Nursing and the Administrator revealed that the facility did not have recliners available and expected the resident to purchase one himself. The resident faced difficulties in purchasing a recliner due to financial constraints and the store's payment requirements, which he could not meet. Despite the resident's efforts to work with social services and the facility's administration, no recliner was provided until a staff member found a temporary solution by bringing a torn leather reclining chair from the maintenance area. The facility's inaction persisted despite the resident's clear communication of his needs and the medical necessity for a recliner. The Social Service Director and the Rehab Director both indicated that it was not their responsibility to provide a recliner, and the Administrator did not take steps to ensure the resident was placed on a waitlist for a rental chair. The lack of coordination and support from the facility staff resulted in a delay in meeting the resident's needs, which was only partially addressed when a temporary chair was provided, leading to an improvement in the resident's condition once he was able to elevate his legs.
Failure to Address Resident Food Quality Complaints
Penalty
Summary
The facility failed to promptly address and resolve grievances related to food quality voiced by residents and the Resident Council. Multiple residents, including those with high cognitive function scores, expressed dissatisfaction with the food served, describing it as repetitive, poorly cooked, and unappetizing. These concerns were consistently reported to the Dietary Manager and the Activities Director, yet no effective action was taken to resolve the issues. Interviews with residents revealed ongoing dissatisfaction with the meals provided, with descriptions of the food being institutional, tasteless, and sometimes inedible. Residents reported that they often had to rely on food brought in by family members or purchased outside the facility. Despite these complaints being voiced repeatedly, there was a lack of documentation in the Resident Council and Food Committee meeting minutes, indicating a failure to formally acknowledge and address the grievances. The Activities Director and Dietary Manager were aware of the complaints but did not document them adequately or take substantial steps to improve the situation. The Dietary Manager acknowledged receiving feedback during meetings but claimed that residents did not bring up significant issues. This disconnect between resident feedback and staff response highlights a deficiency in the facility's grievance resolution process, particularly concerning food quality concerns.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #128, was free from the use of physical restraints, which is a violation of their policy and regulatory requirements. The resident, who was admitted to the facility and later to Hospice services, had a history of falls and was severely cognitively impaired, requiring substantial assistance for mobility. Despite the facility's policy against restraints, a seatbelt was observed attached to the resident's companion chair, which the resident could not remove independently, effectively acting as a restraint. Observations and interviews revealed that the seatbelt was used on multiple occasions, despite the facility's restraint-free policy. The resident's son and daughter expressed concerns about the resident's safety due to frequent falls and the perceived lack of adequate staffing in the memory care unit. The daughter acknowledged the regulations regarding restraints but was unsure about the origin of the chair with the seatbelt. Staff interviews confirmed that the seatbelt was not supposed to be used, but it was observed in use during a surveyor's visit, and the resident was unable to stand due to the restraint. Further investigation revealed that the companion chair with the seatbelt was provided by Hospice services upon the resident's admission to their care. Staff members, including a Licensed Practical Nurse and a Hospice Registered Nurse, confirmed the use of the seatbelt and acknowledged that the resident could not unclip it independently. The facility's Director of Nursing confirmed the delivery of the chair, but there was no documented assessment or care plan addressing the use of the seatbelt, highlighting a failure in adhering to the facility's policy and ensuring the resident's freedom from unauthorized restraints.
Inaccurate Resident Assessments for Vision and Medication
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident #48, who was admitted with conditions including heart failure, hypertension, diabetes mellitus, and major depressive disorder, was inaccurately assessed regarding his visual impairment. Despite being legally blind, as confirmed by both the resident and staff, the Minimum Data Set (MDS) assessments consistently documented his vision as adequate. Interviews with staff revealed a lack of awareness and proper documentation of the resident's visual impairment, which was only corrected after the surveyor's review. Resident #60, admitted with a diagnosis of depression, was inaccurately documented in the MDS assessment as receiving antianxiety medication, despite the medication administration records for July and August showing no such orders. This discrepancy was confirmed during an interview with the MDS Director, highlighting a failure in accurately recording the resident's medication regimen.
Inadequate Care Plans for Residents with Catheter and Vision Impairment
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to deficiencies in their care. Resident #91, who has severe cognitive impairment and multiple medical diagnoses, was observed with an improperly placed catheter bag that was not draining correctly. Despite having a care plan for catheter use, the plan did not address the resident's behavior of manipulating the catheter, which was only added after the surveyor's observation. Staff interviews revealed that the issue was known but not documented in the care plan until the surveyor's intervention. Resident #48, who is legally blind, had a care plan that inaccurately reflected his vision status. The care plan initially documented his vision as adequate, despite the resident and staff acknowledging his blindness. The care plan was only revised to reflect his severe vision impairment after the surveyor's observation. Interviews with staff indicated a lack of awareness of the resident's true vision status, leading to inadequate interventions for his condition. These deficiencies highlight the facility's failure to maintain accurate and comprehensive care plans that address the specific needs and conditions of the residents. The lack of timely updates and accurate documentation in the care plans resulted in inadequate care and oversight for the residents involved.
Failure to Revise Care Plans for Aggression and Fluid Restriction
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #81, who was admitted to the facility and had been involved in two resident-to-resident altercations, did not have any documentation related to physical aggression or conflicts in their care plan. Despite discussions in a morning meeting about adding this information, it was not included, and the Director of Nursing (DON) was surprised by the omission. The Social Services Director (SSD) indicated that the Minimum Data Set (MDS) staff were expected to update the care plans, but this was not done. Resident #79, diagnosed with End Stage Renal Disease and previously on a fluid restriction, had a care plan that inaccurately documented a fluid restriction order that had been discontinued. The care plan, which had been revised multiple times, still included the outdated fluid restriction information. The DON was informed of this discrepancy but could not provide an explanation or further information by the time of the survey exit conference.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required substantial assistance due to medically complex conditions. The resident, who was cognitively intact, expressed feelings of depression and had an ADL self-care deficit related to cellulitis. The resident was occasionally incontinent of urine and frequently incontinent of bowel, necessitating regular assistance with toileting and hygiene. On a specific day, the resident reported having a bowel movement and being changed by a CNA, but later wet her adult depends and requested assistance to be changed again. The CNA dismissed the request, stating it was only urine, and left the resident in wet depends until the next shift arrived. Interviews with staff revealed that the resident had requested to use the bathroom and be transferred back to her wheelchair, but the CNA refused, citing difficulty in performing the task. The resident was left in bed to watch TV without being changed or transferred as requested. The social service director was informed of the resident's concerns regarding the lack of care and services provided. This incident highlights a deficiency in the facility's ability to meet the resident's needs for personal hygiene and mobility assistance, as outlined in her care plan.
Coordination of Hospice Care and Equipment Deficiencies
Penalty
Summary
The facility failed to ensure proper coordination of care and services for two residents receiving hospice care. For one resident, there was a lack of documented orders for hospice services and oxygen use, despite the resident being admitted to hospice care and receiving oxygen for comfort. Observations revealed the resident was on oxygen without any formal order, and staff were unaware of the existing orders or the resident's oxygen use history. The Unit Manager confirmed the resident was on hospice services but could not locate any orders for hospice or oxygen. For the second resident, there was a failure to coordinate the provision of an offloading boot, and the facility lacked the Certificate of Terminal Illness paperwork and current hospice notes. The resident, who had a terminal illness and pressure ulcers, was observed without proper offloading of the foot, which was directly on the mattress or pillow. The Wound Care Nurse and CNA were unsure about the presence or use of an offloading boot, and there was no order for such a boot, despite documentation indicating its necessity. Interviews with staff revealed a lack of communication and follow-up regarding the hospice services and necessary equipment for the residents. The Wound Care Nurse acknowledged the absence of a pressure-relieving boot and stated that hospice would assess the need for one. The Director of Nursing agreed that there were no hospice notes since the resident's admission, indicating a significant gap in documentation and coordination of care.
Failure to Prevent Falls and Update Care Plan for Resident
Penalty
Summary
The facility failed to adhere to its fall prevention policy for Resident #128, who had a history of falls and was at risk for further incidents. Despite multiple falls occurring over several months, the facility did not consistently update the resident's care plan with new interventions or adequately supervise the resident to prevent further falls. The resident experienced numerous falls, some resulting in injuries, yet the care plan often lacked new or effective interventions to address the recurring issue. Resident #128 was admitted with a known history of falls and was assessed as being at risk for falls. The resident experienced several falls, including incidents where she was found on the floor in other residents' rooms, tripped over a floor mat, and fell after a door was opened. Despite these incidents, the facility's interdisciplinary team (IDT) often failed to implement new interventions or update the care plan appropriately. For example, after a fall on 03/30/24, the IDT did not add any new interventions, and similar inaction was noted after subsequent falls. Interviews with the resident's family and staff highlighted concerns about inadequate staffing and supervision, particularly in the memory care unit where Resident #128 resided. The resident's daughter expressed frustration over the repeated falls and the perceived lack of staff to provide necessary supervision. Staff interviews revealed that the unit was often understaffed, with insufficient CNAs to meet the needs of residents with cognitive impairments, which contributed to the inability to prevent falls effectively.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to secure medication storage on two of its five units, as observed by surveyors. On the designated memory care unit, a medication cart was left unlocked and unattended in the common area, with bubble pack medication cards visible on top. Staff K, an LPN, was observed working at a desk on the other side of the common area and later assisting a resident with lunch, leaving the cart unsecured for over two hours. During this time, cognitively impaired residents were present in the area, and Staff K was unaware that both the medication and treatment carts were unlocked. In another instance, a medication cart was found unattended between rooms, with unsecured tubes of Zinc Oxide in a bin on the side. Additionally, a treatment cart was observed unlocked and unattended in the common area, with nine cognitively impaired residents present. Staff K, LPN, stated she had not used the treatment cart that day and was unaware it was unlocked. These observations indicate a failure to adhere to protocols for securing medication and treatment carts, posing potential risks to residents.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete and current medical records for three residents, leading to deficiencies in documentation and care coordination. Resident #5, who was admitted to the facility, reported not having seen a podiatrist despite having thick elongated toenails. The electronic medical record lacked any documentation of podiatry services, and the Social Services Director (SSD) was unable to provide evidence of such services. Additionally, the SSD admitted to not having seen any psychologist notes and had not taken action to address the absence of consultant progress notes in the medical records. Resident #26 had an order for a follow-up appointment with an orthopedic physician, but the record lacked evidence of the appointment or any reason for its absence. The Director of Nursing (DON) could not provide documentation related to the follow-up. Resident #81, who was being monitored for behaviors and had two altercations since admission, had no psychological notes since 2023. Staff interviews revealed that the psychologist's notes were supposed to be sent via email to Medical Records, but this was not occurring routinely, leading to incomplete documentation in the resident's medical records.
Failure to Properly Explain and Document Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained to residents or their representatives in a manner they understood, and did not obtain proper signatures from residents who agreed to the arbitration agreement. This deficiency was identified for two residents, both of whom had intact cognition as indicated by their BIMS scores of 15/15. During interviews, both residents confirmed that they were asked to sign documents related to arbitration but were not given explanations about what they were signing. Additionally, they did not receive copies of the arbitration agreements, and their signatures were not obtained electronically as required. The issue arose due to a lack of proper training and communication among the facility staff. The Marketing Director and Administrator acknowledged that the new Admissions Director, who had not yet been trained, was responsible for obtaining the signatures. The Admissions Director admitted to not using the electronic signature process and not providing copies of the agreements to the residents. The facility's list of residents who agreed to arbitration was also inaccurate, as it did not reflect the absence of electronic signatures on the agreements.
Deficiencies in Call System Accessibility
Penalty
Summary
The facility failed to maintain a functioning call system for one resident and failed to ensure the call light was accessible for another resident. Resident #27, who was cognitively intact with a BIMS score of 13, was unable to signal for assistance as the call system did not function. During an interview, the resident attempted to use the call light, but there was no indication at the nurse's station or over the door that the call had been initiated. This issue was confirmed by a Licensed Practical Nurse who was present at the time. Additionally, Resident #95, also cognitively intact with a BIMS score of 13, was unable to reach the call light due to its improper placement. The call light cord was tightly wrapped around the bedrail, and the button was positioned underneath the bed, making it inaccessible to the resident. The Environmental Services Director was informed of the issue and struggled to untangle the cord, highlighting the inaccessibility of the call light for the resident.
Failure to Timely Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the timely posting of nurse staffing information on four out of five days during the survey period. On 09/09/24, upon entrance at 8:40 AM, the nurse staffing information, which should include the number of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants along with their actual hours worked, was not posted in the lobby area. A subsequent walk-through at 9:09 AM confirmed the absence of this information in the lobby and all units in the main building. On the following days, the nurse staffing information for 09/09/24, 09/10/24, and 09/11/24 was found on the receptionist's desk in the lobby, but not posted as required. During an interview on 09/13/24, the Administrator stated that the responsibility for posting the nurse staffing information at the beginning of each shift lay with the night supervisor and the receptionist. However, the staff at the receptionist desk was unsure of who was responsible, indicating a lack of clarity and communication regarding this duty.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as observed during two separate tours conducted with the Maintenance Director and Housekeeping Manager. Several deficiencies were noted, including torn wheelchair armrests, dirty floors with debris, and unclean toilets. Residents reported longstanding issues, such as a pill on the floor that had been there for a month and dirty windows and blinds. Additionally, a large brown stain was observed on a mattress, and a used COVID test was found on a windowsill. The caulking around a toilet was discolored and cracked, and a door in the Rehab Unit was difficult to open. Interviews with residents and the Housekeeping Supervisor revealed that cleaning was inadequate, with reports of only garbage cans being emptied and floors remaining dirty. Despite claims from the Housekeeping Supervisor that cleaning had been performed, the surveyor found that the pill remained on the floor, the toilet was unclean, and the floor was still dirty. The Housekeeping Supervisor acknowledged these findings but was unable to explain why the cleaning was not completed as expected.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff adhered to physician orders for administering blood pressure medication to a resident with a history of hypertension, orthostatic hypotension, atrial fibrillation, and falls. The physician's orders specified that Diltiazem and Metoprolol should be withheld if the resident's systolic blood pressure (SBP) was below 105 or heart rate (HR) was below 60. Despite these instructions, the medications were administered on multiple occasions when the resident's SBP was below the specified threshold. The Director of Nursing confirmed that the medications should have been held according to the orders. Additionally, the facility did not follow physician orders for the application and maintenance of a wound vac for another resident who had been hospitalized for an infected sacral ulcer resulting in sepsis. The orders required the wound vac to be applied and changed three times a week, but there was no documentation indicating that this care was provided. Interviews with nursing staff revealed a lack of clarity and training regarding responsibility for wound vac care, especially in the absence of the designated wound care nurse. The facility's documentation and staffing practices contributed to the deficiencies. The wound care nurse was unavailable during a critical period, and there was no replacement or clear delegation of responsibilities to other nursing staff. Interviews with various staff members highlighted inconsistencies in understanding and executing wound care duties, with some staff expressing a need for additional training. The Director of Nursing was unable to provide documentation confirming that the wound vac orders were followed, indicating a lapse in adherence to prescribed care protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 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) |
|---|---|---|---|---|
| Sea Breeze Rehab And Nursing Center | 0 mi | ★★★★★ | 18 | 0 |
| Palm Garden Of Vero Beach | 0.1 mi | ★★★★★ | 2 | 0 |
| Hidden Lakes Senior Living Community | 0.7 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.