Average — CMS composite of the measures below.
The next survey window likely opens around May 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 Vivo Healthcare Clewiston during CMS and state inspections, most recent first.
Significant Medication Error Involving Morphine Administration: An LPN gave a resident the wrong morphine medication multiple times after the resident complained of SOB and anxiety. The resident had COPD, HF, pulmonary HTN, adult failure to thrive, and chronic respiratory failure with hypoxia, and the DON stated there was no annual competency review for licensed nurses, no root cause investigation, and no recent med pass observations.
A resident with MS, seizure disorder, malnutrition, and a G-tube was observed receiving enteral nutrition with a feeding pump, pole, base, and surrounding floor visibly soiled with dried brown splashes and residue of formula. The same condition remained on repeated observations over several days, and the DON stated nurses should have cleaned the equipment while the ADM said no one was specifically assigned to monitor resident equipment and housekeeping sometimes cleans the poles.
A resident who needed substantial to maximum help with personal hygiene did not receive routine nail care as planned. Staff documentation stated the resident’s nails were cleaned and trimmed, but observations showed the fingernails were still about one inch long, jagged, and dirty, and the resident said no one had asked about nail care or trimmed the nails despite his inability to do it himself.
A resident with severe cognitive impairment, dementia, COPD, malnutrition, and dependence for bed mobility had bilateral bed bolsters used as a fall intervention to keep him from falling out of bed. Surveyors observed the bolsters tied to raised grab bars, and staff and the resident's POA stated the resident still fell despite their use. The record showed falls before and after the bolsters were implemented, and there were no assessments, informed consents, or physician orders for the bolsters.
A resident in a long-term care facility suffered a major injury after a CNA failed to follow safety precautions during care. The CNA attempted to turn the resident alone, despite the Kardex indicating a two-person assist was required. The resident fell and sustained a hematoma, leading to hospitalization. The CNA was unaware of the requirement and had not been trained to check the Kardex for such information.
A facility failed to document and communicate the need for two-person assistance for a resident with decreased cognition and mobility. A CNA, unaware of this requirement, attempted to reposition the resident alone, resulting in a fall and injuries. The lack of documentation in the care plan and Kardex contributed to the incident.
A resident with decreased cognition and mobility required two-person assistance for bed mobility, but this was not documented in the care plan or Kardex. A CNA, unaware of this requirement, attempted to reposition the resident alone, resulting in a fall and injury. The facility's failure to document and communicate the resident's care needs led to this deficiency.
A resident suffered a significant injury after a CNA failed to follow safety precautions during care. The CNA, unaware of the requirement for two-person assistance, attempted to reposition the resident alone, resulting in a fall and subsequent hospitalization. The facility's failure to communicate the resident's care needs effectively contributed to the incident.
The facility failed to complete quarterly MDS assessments within the required 92-day timeframe for 14 residents, with delays ranging from 130 to 183 days. The part-time status of the MDS coordinator contributed to the inability to meet assessment deadlines, affecting all residents in the facility.
The facility failed to maintain personal hygiene for two residents, one with Alzheimer's and another with lung cancer. Both residents were found with dirty fingernails and unshaven, and there was no documentation to confirm they received their scheduled showers. Interviews revealed flaws in the facility's documentation process.
The facility failed to provide an ongoing program of activities to meet the residents' interests and support their physical, mental, and psychosocial well-being. Four residents were observed without engagement in activities, despite their care plans specifying their preferences. The Activity Director was not present during the day to supervise activities, and there were no programs for residents who only spoke Creole.
The facility failed to ensure the comprehensive assessment accurately reflected the dental status of two residents. Both residents were edentulous, but their Admission MDS assessments did not indicate this. The MDS Coordinator relied on nursing documentation without personally assessing the residents' oral status, leading to discrepancies in their dental records.
The facility failed to ensure the timely completion and transmission of Quarterly MDS data to CMS for two residents. The assessments were significantly delayed, and the MDS coordinator confirmed the delays. The VP of Clinical Services/Risk Management cited staffing issues as a contributing factor.
The facility failed to maintain urinary catheters in a safe and sanitary manner for a resident with an indwelling urinary catheter. The catheter drainage bag was observed on a safety mat on the floor, with the drainage spout open at one point, contrary to facility policy. The LPN was unaware of the proper procedure.
The facility failed to assess three residents for alternative interventions and the danger of entrapment before using bed rails. Additionally, the residents or their representatives were not informed of the risks and benefits of bed rails, nor was informed consent obtained. This deficiency was identified through observations, staff and resident interviews, and record reviews.
Significant Medication Error Involving Morphine Administration
Penalty
Summary
The facility failed to ensure freedom from a significant medication error for one resident who was receiving hospice services and had diagnoses including COPD, heart failure, pulmonary hypertension, adult failure to thrive, and chronic respiratory failure with hypoxia. The resident complained of shortness of breath and anxiety, and an LPN documented that PRN morphine sulfate 0.5 ml was given with little relief. The nurse then documented that she mistakenly administered a 30 mg MS Contin tablet scheduled for every 8 hours instead of the PRN morphine sulfate concentrate ordered for pain or shortness of breath. The resident’s orders included MS Contin 30 mg ER every 8 hours and morphine sulfate concentrate 100 mg/5 ml, 0.5 ml every hour as needed. The Medication Monitoring Control Record showed the resident received the scheduled MS Contin at 6:00 a.m., then additional doses at 8:30 a.m., 9:30 a.m., and 11:00 a.m. on the same day. The DON stated the resident was in distress when she assessed her, and the LPN later reported she had given the wrong medication. The DON also stated there was no annual competency review for licensed nurses, no root cause investigation had been completed, and medication administration observations by the pharmacy had not been done recently.
Soiled Feeding Equipment and Room Environment
Penalty
Summary
The facility failed to provide housekeeping services to maintain a clean and sanitary environment for Resident #8. The resident was admitted on 8/13/23 with diagnoses including Multiple Sclerosis, seizure disorder, and malnutrition. A Significant Change in Status MDS with an assessment reference date of 4/16/26 showed the resident received nutrition through a gastrostomy feeding tube. On 6/1/26 at 10:00 a.m., Resident #8 was observed in bed receiving enteral nutrition via a gastrostomy tube connected to a feeding pump mounted on a pole. The pump, pole, five-legged base, and surrounding floor were visibly soiled with multiple dried brown splashes and residue of enteral formula, and a large puddle of dried-up residue was observed on the floor under the base of the pole. During multiple later observations on 6/2/26, 6/3/26, and 6/4/26, the pump, pole, and surrounding floor remained soiled with the same dried brown splashes and residue. On 6/4/26, the DON stated the nurses should have cleaned the pump, pole, and floor, and the Administrator stated there was no one specifically assigned to monitor residents' equipment and that housekeeping sometimes cleans the poles.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide routine nail care to meet the needs and preferences of a resident who was dependent on staff for ADL assistance. The resident was admitted with diagnoses including muscle wasting and atrophy, diabetes type 2, and pneumonia. The admission MDS indicated intact cognition and that the resident required substantial to maximum assistance with personal hygiene. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and the CNA documentation showed nail care entries on two occasions after admission. During observation, the resident’s right-hand fingernails were found to be about one inch long, jagged, and with a black substance under the nails. The resident stated that no one had asked about nail care since admission, that he did not have a nail clipper, and that he could not clip his own fingernails; he said he would have wanted them clipped or filed. Although a nurse later documented that the resident’s nails were cleaned and trimmed, the nails were again observed to remain long and dirty, and the resident said no one had trimmed them. Staff interviews showed the CNA said she had performed nail care and that the nails were not long, while the OT, LPN, unit manager, and DON acknowledged the nails were long and that the documentation stating nail care had been completed should not have been entered when it was not.
Bed Bolsters Used Without Assessment or Order
Penalty
Summary
The facility failed to evaluate and determine whether the use of bed bolsters was an appropriate and effective intervention to minimize falls for a resident with severe cognitive impairment and significant mobility dependence. The resident was readmitted with diagnoses including sepsis following a wound procedure, respiratory failure with hypoxia, COPD, malnutrition, and dementia. The quarterly MDS showed a Brief Interview for Mental Status score of 3 out of 15, and the resident was dependent for rolling in bed and for chair-to-bed transfer. The care plan identified a fall risk related to decreased mobility, opioid use, and the resident tending to place himself on the floor from bed, with interventions including bilateral bolsters to the bed, nonskid socks, a landing to the left side of the bed, and a low bed. Survey observations showed the resident lying in bed with rectangular padded bolsters positioned along the inner sides of the bed and tied to raised grab bars on both sides, extending higher than the grab bars. Interviews with the DOR, LPN unit manager, DON, and the resident's daughter/POA confirmed the bolsters were used to keep the resident from falling out of bed and that the resident had still fallen with the bolsters in place. Staff acknowledged the bolsters prevented access to the grab bars for repositioning, and the LPN stated the bolsters were not effective because the resident had fallen despite them. Review of the clinical record showed falls before and after the wedges were implemented, and there were no assessments, informed consents, or physician orders for the wedge bolsters.
Neglect Leads to Resident Injury Due to Inadequate Assistance
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a major injury. A Certified Nursing Assistant (CNA) was providing care to a resident and attempted to turn the resident on his left side to remove his brief. During this process, the resident moved off the bed and fell, sustaining a red discoloration and a hematoma on his right side. The resident was subsequently transferred to a local hospital and diagnosed with an acute intra-axial hematoma within the left frontal lobe. The investigation revealed that the CNA did not follow the facility's policy and procedures, which required reviewing the resident's Kardex for specific care instructions. The Kardex indicated that the resident required the physical assistance of two persons for bed mobility, including turning and repositioning, which was not followed. The CNA was unaware of this requirement and had been performing the task alone, leading to the resident's fall and injury. Interviews with staff indicated that the Kardex was regularly updated, and staff were expected to review it at the beginning of each shift. However, the CNA involved in the incident claimed she was not informed about the two-person assist requirement and had not been trained to check the Kardex for such information. The facility verified the neglect allegation and noted that the CNA would be terminated for failing to adhere to the established procedures.
Plan Of Correction
for those residents found to have been affected by the deficient practice: - On [date], upon immediate discovery resident #999 was assessed, received first aid, and transferred to a higher level of care for further evaluation and treatment as indicated. - On [date], investigation immediately initiated, Staff member A suspended pending the outcome of the investigation. - On [date], staff member A along with the Executive Director performed a reenactment of the incident that resulted in a mechanical [incident]. It revealed the stakeholder failed to follow policy and performed toileting hygiene, which includes bed mobility independently. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - A quality review was performed on [date] by the Executive Director and DCS of all residents that reside in the facility in which staff member A provided care to ensure no other residents sustained a [incident] due to improper bed mobility and free from [neglect]. No discrepancies noted. - A quality review was performed on [date] by the Director/ DCS/UM of all residents that reside in the facility of their Kardex and Careplan ensuring that bed mobility was present and accurate. No noted discrepancies. The information was present, accurate and accessible to all nursing staff. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - On [date], and ongoing the nursing staff re-educated by the DCS/ Designee regarding the components of this regulation with the emphasis on the following: "Kardex use - ensuring the Kardex is reviewed and followed prior to providing care for the resident." - "Bed mobility - ensure proper bed mobility is used to include but not limited to the correct number of people to complete the task and always roll a resident towards you never away. Ensure the proper number of people are present to perform the task(s)." - And ongoing all staff re-educated by the DCS/designee regarding the components of this regulation with the emphasis on the following: [neglect] and [abuse] - ensure that while providing care policies and procedures are being adhered to and no intentional neglect is being performed while providing care. - On [date] - ongoing the implementation of enhanced task added to the Kardex for a quicker review for staff to see the residents' need for assistance such as: dependent, extensive, limited, supervision or independent care needed. 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 DCS/ designee will conduct audits on 10 residents weekly x 4, then bi-weekly x 4, then monthly x 1 and PRN on the following: - "Ensure the Kardex has the enhanced task present." - "Ensure task for new admissions and residents with a change in ADLs are promptly updated to reflect current condition." - "Ensure policy and procedures are being followed." - "Ensure stakeholder(s) are not providing neglectful care." The findings of these quality monitoring to be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on the findings with quarterly monitoring by the Regional Director of Clinical Services/ designee.
Failure to Document and Communicate Resident Assistance Needs
Penalty
Summary
The facility failed to ensure that safety interventions were documented in the care plan and that staff used safe repositioning techniques to prevent avoidable injuries. Resident #999, a male with decreased cognition and mobility, required the physical assistance of two persons for bed mobility, as noted in the New Admission Evaluation form. However, this requirement was not specified in the resident's care plan or the Kardex, leading to a lack of awareness among staff about the necessary assistance level. On the day of the incident, Certified Nursing Assistant (CNA) Staff A was changing Resident #999 and attempted to reposition him without assistance. During the process, the resident moved and fell off the bed, resulting in a hematoma and other injuries. CNA Staff A was unaware that the resident required two-person assistance, as this information was not documented in the Kardex or communicated to her. She had previously cared for the resident without incident and was not informed of the need for additional assistance. The facility's investigation revealed that CNA Staff A had not been educated on the proper positioning techniques or the importance of reviewing the Kardex for transfer status. The lack of documentation and communication regarding the resident's care needs contributed to the incident, highlighting a deficiency in the facility's procedures for ensuring resident safety and adequate supervision.
Plan Of Correction
1. What corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice: - On upon immediate discovery the resident # 999 received first aid and transferred to a higher level of care for evaluation and treatment as indicated by Staff member B. - Resident #999 no longer resided at the facility. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - Quality review performed on by DCS/designee of the residents in which Staff member A provided care to ensure no other resident sustained a or injuries related to her failure to follow the Kardex and policy 2- dependent and procedures for bed mobility (assist of care). No deficient practice noted. - Quality review performed on by DCS/designee of all residents that reside in the facility to ensure no injuries were sustained during care and stakeholders were utilizing the Kardex to provide proper care. No deficient practice noted. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - On and ongoing nursing staff re-educated on the components of this regulation with emphasis on: - Stakeholders aware to review Kardex prior to providing care. - Stakeholders are to ensure they have the correct number of Staff members to provide care. - Stakeholders are to ensure proper bed mobility (always turn a resident toward you not away). - "Ensure stakeholders are efficient and familiar with Policy, procedures and processes prior to caring for residents through continual education, competencies and monitoring. 4. How the corrective action (s) will be monitored to ensure the practice will not recur, ie what Quality Assurance program will be put in place: The DCS/designee will conduct audits on 10 residents weekly x 4, then bi-wkly x 4, then monthly x 1 and PRN on the following: - Ensure resident is free from injury while receiving care. - Ensure Kardex is followed and appropriate care provided. The findings of these quality monitoring to be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/ designee.
Failure to Document and Communicate Care Needs Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that safety interventions were documented in the care plan and that staff used safe repositioning techniques, leading to an avoidable injury for Resident #999. The resident, who had decreased cognition and mobility, required the physical assistance of two persons for bed mobility, as noted in the New Admission Evaluation form. However, this requirement was not specified in the care plan or the Kardex, which is used for communication and organization of resident care summaries. During an incident, Certified Nursing Assistant (CNA) Staff A was changing Resident #999 and attempted to reposition him without assistance. The resident began to move off the bed, and despite CNA Staff A's attempt to hold him, he fell to the floor, resulting in a hematoma and other injuries. The CNA was unaware that the resident required two-person assistance, as this information was not documented in the Kardex or communicated to her. The facility's investigation revealed that CNA Staff A had not been informed of the two-person assist requirement and had not encountered issues with the resident previously. The investigation also noted that the resident was not positioned correctly during the repositioning attempt, contributing to the fall. The lack of proper documentation and communication regarding the resident's care needs led to the deficiency in providing adequate and appropriate health care services.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Upon immediate discovery, the resident #999 received first aid and was transferred to a higher level of care for evaluation and treatment as indicated by Staff member B. - Resident #999 no longer resided at the facility. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - Quality review performed by DCS/designee of the residents in which Staff member A provided care to ensure no other resident sustained injuries related to her failure to follow the Kardex and policy and procedures for bed mobility (assist of 2-dependent care). No deficient practice noted. - Quality review performed by DCS/designee of all residents that reside in the facility to ensure no injuries were sustained during care and stakeholders were utilizing the Kardex to provide proper care. No deficient practice noted. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - Ongoing nursing staff re-educated on the components of this regulation with emphasis on: - Stakeholders aware to review Kardex prior to providing care. - Stakeholders are to ensure they have the correct number of staff members to provide care. - Stakeholders are to ensure proper bed mobility (always turn a resident toward you, not away). - Ensure stakeholders are efficient and familiar with policy, procedures, and processes prior to caring for residents through continual education, competencies, and monitoring. 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 DCS/designee will conduct audits on 10 residents weekly x 4, then bi-weekly x 4, then monthly x 1 and PRN on the following: - Ensure resident is free from injury while receiving care. - Ensure Kardex is followed and appropriate care provided. The findings of these quality monitoring will be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.
Neglect Leads to Resident Injury Due to Inadequate Assistance
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a significant injury. A Certified Nursing Assistant (CNA) was providing care to a resident, identified as Resident #999, and attempted to turn the resident on his left side to remove his brief and bed sheet. During this process, the resident moved off the bed and fell, sustaining a red discoloration and a hematoma on the right side of his body. The resident was subsequently transferred to a local hospital and diagnosed with an acute intra-axial injury within the left frontal region. The investigation revealed that the CNA did not follow the facility's policy and procedures, which required reviewing the resident's Kardex for specific care instructions. The Kardex indicated that Resident #999 required the physical assistance of two persons for bed mobility, a detail that was not communicated to the CNA. The CNA, unaware of this requirement, attempted to reposition the resident alone, leading to the fall. The CNA admitted to not knowing about the Kardex and stated that she had always assisted the resident by herself without being informed of the two-person assist requirement. Interviews with facility staff, including the Unit Manager and other Registered Nurses, confirmed that the Kardex is regularly updated and should be reviewed at the beginning of each shift. However, the CNA did not receive this information prior to the incident. The facility verified the neglect allegation and noted that the CNA would be terminated for failing to adhere to the established procedures. The resident's care plan and admission assessments clearly indicated the need for two-person assistance, which was not communicated effectively to the CNA involved in the incident.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On [date], upon immediate discovery, resident #999 was assessed, received first aid, and transferred to a higher level of care for further evaluation and treatment as indicated. - On [date], investigation immediately initiated, Staff member A suspended pending the outcome of the investigation. - On [date], staff member A along with the Executive Director performed a reenactment of the incident that resulted in a mechanical [incident]. It revealed the stakeholder failed to follow policy and performed toileting hygiene, which includes bed mobility independently. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - A quality review was performed on [date] by the Executive Director and DCS of all residents that reside in the facility in which staff member A provided care to ensure no other residents sustained a [incident] due to improper bed mobility and were free from [incident] or neglect. No discrepancies noted. - A quality review was performed on [date] by the Director/DCS/UM of all residents that reside in the facility of their Kardex and Careplan ensuring that bed mobility was present and accurate. No noted discrepancies. The information was present, accurate, and accessible to all nursing staff. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - On [date] and ongoing, the nursing staff re-educated by the DCS/Designee regarding the components of this regulation with the emphasis on the following: "Kardex use - ensuring the Kardex is reviewed and followed prior to providing care for the resident." - "Bed mobility - ensure proper bed mobility is used to include but not limited to the correct number of people to complete the task and always roll a resident towards you never away. Ensure the proper number of people are present to perform the task(s)." - And ongoing, all staff re-educated by the DCS/designee regarding the components of this regulation with the emphasis on the following: neglect and - ensure that while providing care, policies and procedures are being adhered to and no intentional neglect is being performed while providing care. - "On [date] - ongoing the implementation of enhanced task added to the Kardex for a quicker review for staff to see the residents' need for assistance such as: dependent, extensive, limited, supervision, or independent care needed." 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 DCS/designee will conduct audits on 10 residents weekly x 4, then bi-weekly x 4, then monthly x 1 and PRN on the following: - "Ensure the Kardex has the enhanced task present." - "Ensure task for new admissions and residents with a change in ADLs are promptly updated to reflect current condition." - "Ensure policy and procedures are being followed." - "Ensure stakeholder(s) are not providing neglectful care." - The findings of these quality monitoring to be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on the findings with quarterly monitoring by the Regional Director of Clinical Services/designee.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure the completion of the quarterly Minimum Data Set (MDS) assessments within 92 days from the assessment reference date of the last completed assessment for 14 residents. This deficiency was identified through record reviews and staff interviews. The residents involved had significant delays in their quarterly assessments, ranging from 130 to 183 days after their admission assessments. These delays had the potential to hinder timely assessment and revision of the residents' care plans, which are crucial for monitoring gradual changes in their status between comprehensive assessments. The MDS coordinator, who is responsible for completing these assessments, acknowledged during an interview that the quarterly assessments for the 14 residents were not completed within the required timeframe. The coordinator attributed the delays to her part-time work schedule, which made it challenging to complete all the necessary MDS assessments on time. This issue was not isolated to the sampled residents but affected all residents in the facility. The Vice President of Clinical Services/Risk Management confirmed the facility's struggle to complete all the MDS assessments. The VP stated that the part-time status of the MDS nurse contributed to the inability to meet the assessment deadlines. This systemic issue highlights the facility's ongoing challenge in maintaining compliance with the required assessment schedule, potentially impacting the quality of care provided to the residents.
Failure to Maintain Personal Hygiene for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for two residents, Resident #81 and Resident #303. Resident #81, who has a history of Alzheimer's disease and other medical conditions, was observed with long, dirty fingernails, unshaven facial hair, and a malodorous body odor. Despite being scheduled for showers three times a week, there was no documentation to confirm that these showers were provided. The resident expressed that he needed assistance with shaving and nail care, but the facility's records did not reflect consistent care being given. Resident #303, who has diagnoses including bipolar disorder and lung cancer with metastasis to the brain, was found with dirty fingernails and a sticky substance under her nails. She could not recall the last time she had a shower. The facility's records showed inconsistencies in the scheduling and documentation of her showers, with no clear evidence that the resident received her scheduled showers. The facility was unable to provide documentation from the hospice care team that was supposed to assist with her hygiene. Interviews with staff, including a CNA and the DON, revealed that the facility's process for documenting showers was flawed, with shower sheets being shredded after review by the nurse. This lack of proper documentation and follow-up led to the failure in maintaining the residents' personal hygiene as per their care plans.
Failure to Provide Ongoing Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the residents' interests and support their physical, mental, and psychosocial well-being. This deficiency was observed in four residents who were reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. Resident #8, who had diagnoses including dementia, psychosis, major depressive disorder, and anxiety, was observed multiple times in her room without any engagement in activities. Despite the care plan specifying that she enjoyed listening to music, watching television, and participating in religious activities, she was found in a dark room with no music or television turned on. The activity calendar listed various activities, but there was no evidence that Resident #8 participated in any of them. Resident #42, who had diagnoses including dementia, Alzheimer's, anxiety, and major depressive disorder, was also observed multiple times in her room sleeping without any engagement in activities. Her care plan specified that she enjoyed listening to Spanish music and watching Spanish television shows and movies. However, there was no evidence that these activities were provided. The activity logbook inaccurately documented her participation in activities, and staff interviews revealed that the Activity Director was not present during the day to supervise the activities. Residents #51 and #82, both of whom primarily spoke Creole, were observed in their rooms without any engagement in activities. Their care plans specified that they enjoyed listening to Creole music and watching television. However, there was no evidence that these activities were provided. The Activity Director confirmed that the residents did not have the necessary equipment, such as a radio/CD player with Creole music, in their rooms. Staff interviews revealed that there were no activity programs for residents who only spoke Creole, and the activity staff did not consistently conduct the residents' activity programs as required.
Failure to Accurately Reflect Dental Status in Comprehensive Assessments
Penalty
Summary
The facility failed to ensure the comprehensive assessment accurately reflected the dental status of two residents. For Resident #39, the clinical record indicated that the resident was edentulous with two asymptomatic root tips as noted by an outside provider's screening report. However, the Admission Nursing Comprehensive Evaluation and the Admission Minimum Data Set (MDS) assessment did not accurately reflect this status. The MDS Coordinator admitted to relying on nursing documentation without personally assessing the resident's oral status, leading to discrepancies in the resident's dental records. Similarly, Resident #90's clinical record showed that the resident was completely edentulous following an accident. Despite this, the Admission MDS assessment did not indicate that the resident was edentulous. The MDS Coordinator again relied on nursing assessments without conducting a personal examination of the resident's oral condition. This failure to accurately document the residents' dental status was in direct violation of the Resident Assessment Instrument Manual 3.0 instructions, which require a thorough examination of the resident's oral cavity.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to ensure the completion and transmission of completed resident Quarterly Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System within 14 days after a facility completes a resident's assessment for two residents. Resident #17 had an admission assessment done on 8/19/23, but their next Quarterly assessment was not coded and completed for 130 days, and it was transmitted to CMS on 1/2/24. Resident #82 had an admission assessment done on 8/20/23, but their next Quarterly assessment was not coded and completed for 183 days, and it was transmitted to CMS on 2/21/24. The MDS coordinator confirmed that the assessments were not transmitted within the required 14-day timeline. The VP of Clinical Services/Risk Management stated that the facility has been struggling to complete and transmit all MDS assessments on time due to the MDS nurse working part-time.
Failure to Maintain Safe and Sanitary Catheter Care
Penalty
Summary
The facility failed to maintain urinary catheters in a safe and sanitary manner for one resident with an indwelling urinary catheter. The facility's policy required that catheter drainage bags be covered and not placed on the floor. However, observations revealed that the catheter drainage bag of Resident #303 was placed on a safety mat on the floor, with the drainage spout found open at one point. Despite the policy, the Licensed Practical Nurse was unaware that the drainage bag should not be on the mat, indicating a lapse in adherence to the facility's catheter care procedures. Resident #303 had a diagnosis of urinary retention and a care plan aimed at preventing urinary tract infections, but the observed practices did not align with these goals.
Failure to Assess and Inform Residents About Bed Rails
Penalty
Summary
The facility failed to ensure that three residents were assessed for alternative interventions prior to the use of bed rails and did not assess the residents for the danger of entrapment before using bed rails. Additionally, the facility did not inform the residents or their representatives of the risks and benefits of bed rails or obtain informed consent before their use. This deficiency was identified through observations, review of facility policies and procedures, staff and resident interviews, and record reviews. Resident #42, who had diagnoses including falls, dementia, anxiety, major depressive disorder, and Alzheimer's, was observed with 1/2 rails in the raised position on both sides of the upper bed. The facility's Administrator confirmed that there was no additional documentation indicating that alternative interventions were attempted for Resident #42. The Maintenance Director also confirmed that there were no records of inspection for entrapment zones or compatibility of mattresses and bed rails. Resident #100 had 2 quarter side rails on each side of her bed in the up position. She stated that she did not need the siderails and was never informed of the risks and benefits. The facility's Interim Director of Nursing and Vice-President of Clinical Services confirmed that Resident #100 was never assessed for the risk of entrapment nor explained the risks and benefits of side rails. Similarly, Resident #24, who had chronic kidney disease and diabetes mellitus type II, was observed with 1/2 size bed rails elevated on both sides of the upper half of the bed. The resident signed a consent form for the bedrails, but the risks were not explained, and no appropriate alternatives were tried prior to installing the bed rails.
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 27 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 Clewiston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glades Health Care Center | 18 mi | ★★★★★ | 27 | 0 |
| Labelle Health And Rehabilitation Center | 30.3 mi | ★★★★★ | 0 | 0 |
| Okeechobee Health Care Facility | 32.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.