Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westminster Suncoast during CMS and state inspections, most recent first.
Surveyors found that multiple residents with skin tears and skin integrity risks did not receive wound care and skin assessments as ordered. For one resident, dressing changes to a lower extremity skin tear were signed as completed every other day, but the dressing was later found still dated from an earlier change, and required steri-strip monitoring on the hand was not documented every shift. Another resident with a left wrist skin tear had a daily dressing order with a missed treatment date and continued every-other-day dressings despite weekly skin inspections documenting intact skin and no clear weekly skin evaluation in the care plan. A third resident with a right wrist skin tear had an order for four days of daily dressings that continued beyond four days without an end date, and this resident’s weekly skin check was overdue despite a care plan intervention for weekly skin checks. These findings showed failures to follow physician orders, accurately document treatments on the TAR, and complete timely weekly skin assessments.
A resident with dementia, fall history, and skin integrity risk had a physician order for right lower extremity skin tear care every other day on the night shift. The Treatment Administration Record showed that wound care was documented as completed on multiple scheduled dates, but the DON later found the dressing still dated from an earlier application, confirming that ordered dressing changes had not been performed for eight days. Two nurses had signed for treatments that were not provided, and weekly skin checks noted non-intact, non-new skin areas without describing the wound or dressing. This resulted in missed physician-ordered wound care and falsified documentation, contrary to the facility’s policies on neglect prevention, wound treatment management, and accurate medical record documentation.
Surveyors found that medications were not consistently secured, including an IV antibiotic bag left on top of an unattended med cart and oral medications left at a resident’s bedside for at least 30 minutes before an RN returned to administer them. The resident involved was cognitively intact, had multiple medical conditions including a healing femur fracture, hypertension, anxiety, and depression, and was receiving several medications such as antidepressants, antianxiety agents, anticoagulants, opioids, antiplatelet agents, levothyroxine, lisinopril, and pravastatin. There was no documentation that the resident was assessed or care planned to self-administer or delay medications, and staff interviews, along with facility policies, confirmed that medications should remain under direct observation or locked and never be left unattended with residents or on med carts.
A resident with impaired cognition and multiple care needs had several shifts where bowel and bladder tasks were left undocumented, despite facility policy requiring complete, factual, and timely documentation of all care or absence of bowel/bladder events by the end of each shift. The DON confirmed that no bowel and bladder tasks should be left blank and that staff must record when no movement occurs. This lack of documentation conflicted with the CNA job description and the facility’s medical record policy, which mandate accurate, complete records reflecting all assessments, observations, and services provided.
Surveyors found that staff failed to follow contact precautions and PPE requirements for two residents on physician-ordered contact isolation. In one case, a CNA entered and interacted with a resident with loose stools and an active order for contact isolation for possible C. diff without wearing gown or gloves, despite a CDC-based Contact Precautions sign on the door and no PPE available at the doorway. In another case, an Activity Assistant entered the room of a resident with an active order for contact isolation for MSSA wound infection without PPE, even though a Contact Precautions sign was posted and the staff member reported prior education on transmission-based precautions. Facility policies required staff to follow CDC-based transmission-based precautions, including donning gown and gloves upon room entry and discarding them before exit, but these practices were not implemented during the observed interactions.
A resident with multiple diagnoses, including dementia and blindness, was subjected to physical abuse by a staff member in an LTC facility. The resident spat at a registered nurse, who retaliated by spitting back multiple times, witnessed by a CNA. The incident was not reported immediately, and the facility failed to protect the resident from further harm, violating its abuse prevention policies.
A resident with a history of mental health issues was involved in an altercation with an RN, who spat back at the resident and held their hands down. The incident, witnessed by a CNA, was not reported until 39 hours later due to fear of retaliation and lack of immediate action by the nursing supervisor. The facility failed to adhere to the required two-hour reporting timeframe for abuse incidents.
The facility failed to ensure an accurate care plan for a resident with multiple diagnoses, including dysphagia and repeated falls. Despite having a DNR order, the care plan incorrectly listed the resident as Full Code. Staff interviews confirmed that care plans should reflect physician orders, which was not done in this case.
The facility failed to ensure that pressure-relieving boots were applied to prevent the worsening of a pressure wound for a resident. Observations revealed the boots were not in use despite physician orders, and documentation contradicted the actual care provided. Interviews indicated that the responsibility for applying the boots lay with the nursing staff, but this was not consistently done.
The facility failed to properly identify and monitor a BIPAP machine for a resident with multiple medical conditions. The resident used a personal BIPAP machine without any orders or documented settings, and the facility did not follow its policy requiring verification and documentation of the machine's use.
The facility failed to ensure ongoing assessment and monitoring of a resident's dialysis fistula, leading to complications such as bleeding and clotting. Despite physician orders and care plan interventions, staff repeatedly did not complete necessary assessments and documentation before and after dialysis treatments. Interviews revealed that the facility's expectations for monitoring and documenting the dialysis fistula were not consistently met, and staff received limited training on dialysis care.
The facility failed to assess and identify triggers for a resident with PTSD, leading to a lack of specific interventions in the care plan. The Social Services Director admitted the oversight, and the Director of Nursing was not knowledgeable about Trauma Informed Care. The facility's policy requires identifying triggers to minimize re-traumatization, which was not followed.
The facility failed to ensure that a private caregiver for a resident with hemiplegia and hemiparesis had the necessary competencies and skills to provide appropriate care. The caregiver, who was not formally trained as a CNA or nurse, was performing ADL care without oversight from facility staff. Interviews revealed that facility staff were either unaware of the caregiver's involvement or assumed her competence without verification.
Failure to Follow Wound Care Orders and Complete Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and skin assessments as ordered and care planned for multiple residents with non-pressure wounds and skin integrity risks. For one resident with metabolic encephalopathy, repeated falls, and dementia, a physician’s order directed cleansing of right lower extremity skin tears with normal saline, application of xeroform and ABD pad, and gauze wrap every two days on night shift beginning 6/7/25. Documentation on the Treatment Administration Record (TAR) showed treatments recorded on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25 the DON documented that the dressing on the right lower extremity was dated 6/11, despite two nurses having signed that dressing changes were completed on 6/13, 6/15, and 6/17, indicating the ordered dressing changes were not actually performed as documented. Weekly skin evaluations for this resident on 6/14/25 indicated the skin was not intact and the areas were not new, but the progress notes for that date did not include information about the skin evaluation or the existing areas. For the same resident, an order on the TAR required monitoring steri-strips on the left hand for signs and symptoms of infection every shift. The TAR showed code “9” (other/see progress notes) on the day shift of 6/11 and the evening shift of 6/15, and a blank entry for the night shift on 6/12, indicating the monitoring was not documented as completed that shift. Progress notes on 6/11 documented wound care provided by the wound care nurse, but notes on 6/11, 6/12, and 6/13 did not explain why the steri-strip monitoring was not completed on the night shift of 6/12. A 6/15 progress note stated staff had not observed the steri-strips to the left hand. The resident’s care plan identified risk for skin breakdown related to assistance needs, nutritional risk, and prior skin tears, and included interventions for monitoring steri-strips for infection every shift, observing skin condition during routine care every shift, providing treatments as ordered, and weekly skin checks. During interview, the DON stated weekly skin checks were done head to toe but staff were focused on identifying new areas and did not pay attention to dressing dates, even though the care plan did not limit checks to new areas only. Another resident with a left wrist skin tear had an order starting 2/13/26 for daily evening-shift treatment with normal saline, xeroform, and dry sterile dressing until resolved. The TAR showed completion from 2/13 through 2/18/26, with the 2/19/26 entry left blank, indicating the treatment was not documented as completed that day. A new order on 2/20/26 for daily day-shift treatment was started and discontinued the same day, while the dressing changes continued every other day thereafter (2/21, 2/23, 2/25/26) despite weekly skin inspections dated 2/14 and 2/21/26 documenting the skin as intact. The care plan for this resident identified potential for skin impairment related to decreased mobility, impaired cognition, incontinence, and a left wrist skin tear, and directed licensed nursing staff to provide treatments as ordered, but did not include weekly skin evaluations. During observation on 2/25/26, the LPN/Unit Manager stated the dressing change was every other day, and the dressing was dated 2/23/26, which did not match the documented daily treatment orders. A third resident with a right wrist dressing reported that the dressing was changed frequently, and the LPN/Unit Manager stated the changes were every other day. However, the provider note documented an order to cleanse with normal saline, pat dry, apply xeroform, and dry dressing for four days, and the TAR showed the treatment order starting 2/19/26 with daily dressing changes documented for six days, without an end date entered as of 2/25/26. The resident’s electronic record showed the weekly skin inspection was two days overdue, with the last completed weekly skin inspection on 2/16/26 despite a care plan intervention for weekly skin checks by licensed nursing staff. The DON acknowledged that the weekly skin check for this resident was overdue. Overall, record reviews, observations, and interviews showed that wound treatments were not consistently provided as ordered, documentation on the TAR was inaccurate or incomplete, and weekly skin assessments were not completed timely or accurately for the sampled residents, contrary to the facility’s Wound Treatment Management policy requiring treatments per physician orders and ongoing assessment and documentation.
Failure to Provide Ordered Wound Care and Falsification of Treatment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered wound care and accurate documentation for a resident with a non-pressure skin tear on the right lower extremity. The resident had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, and was identified as having intermittent confusion, being chairbound, incontinent, and having balance problems. A physician’s order on the Treatment Administration Record (TAR) directed that the right lower extremity skin tears be cleansed with normal saline, patted dry, covered with xeroform and an ABD pad, and wrapped with gauze every two days on the night shift, beginning on 6/7/25. The TAR showed that wound care was documented as completed on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25, the DON identified that the dressing on the resident’s right lower extremity was still dated 6/11, indicating that the ordered dressing changes had not actually been performed for eight days despite documentation to the contrary. The DON confirmed that two nurses had signed that the dressing changes were completed on 6/13, 6/15, and 6/17, and the surveyor determined that this documentation was false. Weekly skin evaluations documented that the resident’s skin was not intact and that the areas were not new, but there was no further information in the progress notes about the appearance of the wound or the dressing. The resident’s care plan identified risk for skin breakdown related to assistance needs with bed mobility and repositioning, nutritional risk, and prior skin tears, and included interventions such as treatments as ordered, weekly skin checks by licensed staff, and observation of skin condition during routine care. The care plan did not instruct staff to limit skin checks to only new areas, yet the DON stated that staff performing weekly skin checks were focused on identifying new issues and did not pay attention to the date on the existing dressing. Facility policies on abuse, neglect, wound treatment management, and documentation required that ordered treatments be provided as prescribed, that neglect be prevented, and that documentation be factual, accurate, and not false. Despite these policies, the ordered wound treatments were not provided for eight days, and the medical record contained false entries indicating that wound care had been completed as ordered.
Unsecured Medications Left Unattended on Med Cart and at Bedside
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely and not left unattended on medication carts or at residents' bedsides. Surveyors observed a bag of Vancomycin 1 g/200 mL left on top of an unattended medication cart on the 400 hall while the assigned RN was in a resident room on a different hall. The RN later acknowledged the medication should not have been left on top of the cart. The DON stated that medications should not be left unattended on carts, and facility policy on medication storage requires that during a medication pass, medications must be under direct observation of the person administering them or locked in the medication storage area or cart. The deficiency also includes medications left unattended in a resident’s room. A resident was observed with medication at the bedside, and an RN entered the room and immediately went to the medications to administer the remaining dose. The resident reported the medication had been at the bedside for at least 30 minutes and stated staff always leave medications at the bedside so they can take them later. The RN did not comment and removed the empty medication cup after administration. Record review showed this resident was cognitively intact with a BIMS score of 15 and had diagnoses including a left femur neck fracture with routine healing, left hip pain, hypertensive urgency, anxiety disorder, and recurrent moderate major depressive disorder. The resident was receiving multiple medications including antidepressants, antianxiety agents, anticoagulants, opioids, antiplatelet agents, levothyroxine, lisinopril, and pravastatin. There was no documentation in progress notes or the care plan indicating the resident requested to take medications later, no physician or family advisement, and no care plan addressing a tendency to delay or hold medications, despite staff interviews and facility policy stating that medications should not be left unattended with residents.
Failure to Accurately Document Incontinence Care in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident receiving incontinence care. The resident was admitted with diagnoses including need for assistance with personal care, difficulty in walking, speech and language deficits following cerebrovascular disease, and recurrent moderate major depressive disorder. A Quarterly MDS assessment documented a BIMS score of 9, indicating moderately impaired cognition. Review of the resident’s bowel and bladder task documentation showed multiple shifts on which incontinence care entries were left blank, specifically on 8/28/25 (3–11 shift), 9/8/25 (7–3 shift), 9/11/25 (11–7 shift), 9/12/25 (3–11 shift), 9/30/25 (11–7 shift), and 10/5/25 (3–11 shift). These blanks indicated that care or the absence of bowel/bladder events was not documented as required. During an interview, the DON stated that none of the resident’s bowel and bladder tasks should be blank and that staff are expected to document “no bowel or bladder movement” if no care is needed, with all tasks completed by the end of each shift. The facility’s CNA job description requires CNAs to comply with federal and state regulations, make routine and frequent rounds, and avoid skin problems by providing timely incontinence care and repositioning. The facility’s “Documentation in Medical Record” policy, revised 6/2025, requires that each resident’s record accurately represent the resident’s experiences, with complete, accurate, factual, and timely documentation of all assessments, observations, and services, to be completed no later than the shift in which care occurred. The blank bowel and bladder task entries for this resident demonstrate noncompliance with these documentation standards.
Failure to Ensure Staff Use PPE for Residents on Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program by not ensuring staff consistently donned appropriate PPE when caring for residents on contact precautions. For one resident with loose stools and a physician order for contact isolation due to possible Clostridioides difficile (C. diff), a CNA was observed standing in front of the resident, speaking with them, and then leaving the room without wearing any PPE. A Contact Precautions sign from the CDC was posted on the resident’s door, instructing all providers and staff to clean their hands, don gloves and a gown before room entry, and discard them before room exit, and to use dedicated or disinfected equipment. There was no PPE available at the doorway at the time of the observation. During an interview shortly after the observation, the CNA stated that the resident did not have any precautions. The LPN confirmed that the facility was attempting to obtain a stool sample for C. diff because the resident had loose stools. Review of the resident’s record showed an active physician order dated two days prior for “Contact Isolation every shift for possible cdiff for 5 days,” and an order to obtain stool for C. diff and ova and parasites for loose stool for three days. The resident’s diagnoses included multiple fractures of ribs on the left side with routine healing, generalized muscle weakness, and unspecified convulsions. Despite the posted CDC-based Contact Precautions sign and the active contact isolation order, the CNA entered and interacted with the resident without required PPE and later acknowledged that PPE was required and confirmed being in the room without it. A second deficiency event involved another resident with an active physician order for contact isolation every shift for methicillin susceptible Staphylococcus aureus (MSSA) to a wound. An Activity Assistant was observed entering this resident’s room and closing the door without donning any PPE, despite a CDC-based Contact Precautions sign posted on the door that instructed staff to clean their hands before entering and when leaving, don gloves and a gown before room entry, discard them before room exit, and use dedicated or disinfected equipment. No PPE was available in the hallway directly outside the room. The Activity Assistant reported having been educated on transmission-based precautions and PPE use, stated that gloves, mask, gown, and face shield should be worn for contact precautions, and indicated that PPE is used when there are signs on the door. After reading the sign, the staff member noted it included instructions for soap and water hand hygiene. Review of the resident’s record confirmed active orders for contact isolation for MSSA wound infection and enhanced barrier precautions related to IV access and a coude Foley catheter. Review of facility policies showed that the Infection Prevention and Control Program policy required all staff to follow policies and procedures related to infection prevention and to use PPE according to established facility policy, and that residents with infections or communicable diseases be placed on transmission-based precautions per current CDC guidelines. The Transmission-Based (Isolation) Precautions policy defined contact precautions as measures to prevent transmission of infectious agents spread by direct or indirect contact, and specified that healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, donning PPE upon room entry and discarding it before exiting. The policy also identified contact precautions with soap-and-water hand hygiene for C. difficile for the duration of illness. Despite these written policies and CDC-based signage, staff did not consistently don required PPE when entering the rooms of residents on contact precautions, and PPE was not available at the doorway for the observed residents.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect the rights of a resident from physical abuse by a staff member. The incident involved a resident who was blind and had multiple diagnoses, including unspecified cerebral infarction, dementia, major depressive disorder, and adjustment disorder. On the evening of the incident, the resident was reportedly combative and refused care, leading to an altercation with a staff member. During the care process, the resident spat at a registered nurse, who then spat back at the resident multiple times. This exchange was witnessed by a certified nursing assistant who reported the incident to a nursing supervisor. The nursing supervisor, however, did not take immediate action to report the incident further, as she was not the supervisor on duty at the time. The registered nurse involved in the incident admitted to spitting back at the resident and holding the resident's hands down during care. The facility's policy on abuse, neglect, and exploitation clearly prohibits such actions, defining abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. Despite this, the incident was not reported immediately, and the staff member involved was only suspended after the investigation began. The facility's failure to protect the resident from abuse was compounded by the delay in reporting the incident and the lack of immediate protective measures for the resident. The facility's policy requires immediate response to protect residents from harm and to ensure the integrity of investigations. However, in this case, the resident was left vulnerable to further abuse, and the staff member's actions were not addressed promptly, highlighting a significant deficiency in the facility's adherence to its own policies and procedures.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in a timely manner, as required by regulations. The incident occurred when a resident, who had a history of cerebral infarction, dementia, and other mental health issues, was involved in an altercation with a staff member. The resident, who is blind, was reportedly combative and spat at a registered nurse (RN) during care. In response, the RN spat back at the resident and held the resident's hands down. This incident was witnessed by a certified nursing assistant (CNA), who did not report it immediately. The CNA, identified as Staff A, witnessed the incident on a Saturday night but did not report it until the following Monday afternoon, approximately 39 hours later. The delay in reporting was due to fear of retaliation from the RN involved, as well as a lack of immediate action by the nursing supervisor on duty, who advised the CNA to write a statement but did not escalate the report. The facility's policy requires that such incidents be reported within two hours if they involve abuse, which was not adhered to in this case. The facility's management, including the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Health Care Director (RHCD), were informed of the incident only after the delay. They acknowledged the failure to report the incident promptly and noted that the staff involved did not follow the established procedures for reporting abuse. The incident was eventually reported to the state agency and law enforcement, but not within the required timeframe, highlighting a significant deficiency in the facility's handling of abuse allegations.
Failure to Ensure Accurate Advanced Directives in Care Plan
Penalty
Summary
The facility failed to ensure an accurate care plan was in place related to Advanced Directives for one resident. The resident was admitted with multiple diagnoses, including dysphagia, muscle weakness, and repeated falls. Despite having a physician order for Do Not Resuscitate (DNR) dated 4/21/24 and a State of Florida's DNR Order completed by the resident's Durable Power of Attorney and signed by the physician on 3/30/24, the resident's care plan dated 4/5/24 incorrectly listed the resident as Full Code. This discrepancy indicates that the care plan did not reflect the resident's actual advanced directives as documented in the physician orders and state DNR order. Interviews with staff, including the Assistant Social Worker, Director of Nursing (DON), and Nursing Home Administrator (NHA), confirmed that the care plans should accurately reflect the physician orders. The Assistant Social Worker explained that Advanced Directives are obtained by the social services department upon admission and followed up by the nurses after hours. The DON and NHA confirmed that staff should refer to the physician order in the electronic medical record and the hard chart to determine the code status, not the care plan. The facility's policy on Comprehensive Care Plans emphasizes the need for accurate and person-centered care plans, which was not adhered to in this case.
Failure to Apply Pressure-Relieving Boots
Penalty
Summary
The facility failed to ensure that pressure-relieving boots were applied to prevent the worsening of a pressure wound for a resident. Observations on two consecutive days revealed that the resident was in bed with the air boots placed on a chair next to the bed, not in use, despite physician orders for the boots to be applied while in bed every shift. The Treatment Administration Record (TAR) indicated that the boots were documented as administered, although observations contradicted this documentation. Additionally, there was no documentation related to floating heels while in bed every shift as per another physician's order. The resident's medical history included dysphagia, muscle weakness, and repeated falls, among other conditions. The resident had a pressure wound on the left lateral heel, which was documented as stable but required specific treatments, including the use of air boots and floating heels. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) revealed that the responsibility for applying the boots lay with the nursing staff, but the boots were not consistently applied as required. The facility's policy on assistive devices emphasized the need for proper and consistent use based on the resident's care plan, but this was not adhered to in this case.
Failure to Monitor and Document BIPAP Machine Use
Penalty
Summary
The facility failed to ensure proper identification and monitoring of a BIPAP machine for a resident. Resident #6, who had medical diagnoses including heart failure and Type 2 Diabetes Mellitus, was observed using a BIPAP machine that he brought from home. The resident was able to put on and remove the BIPAP mask himself. However, a review of his medical record did not reveal any orders related to the BIPAP machine, and his care plan only mentioned CPAP/BIPAP therapy without specific details or settings for the BIPAP machine. An interview with the Director of Nursing confirmed that there should have been an order for the BIPAP settings and that a respiratory therapist should have been involved in confirming the settings. The facility's policy on noninvasive ventilation required obtaining an order for the use of CPAP/BIPAP devices and verifying the settings on any personal devices brought into the facility. The policy also mandated documentation of the machine's use, the resident's tolerance, and any changes in the resident's condition, which was not done in this case.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring of the dialysis fistula for a resident requiring dialysis services. The resident, who had a history of End Stage Renal Disease and dependence on renal dialysis, experienced complications with her dialysis access port, including bleeding and clotting. Despite physician orders and care plan interventions requiring thorough monitoring and documentation of the dialysis fistula, the facility staff repeatedly failed to complete the necessary assessments and documentation before and after dialysis treatments. This included not recording vital signs, thrill and bruit assessments, and signs of bleeding or infection on multiple occasions, as evidenced by the incomplete Dialysis Communication Inter-Change forms and progress notes reviewed by surveyors. On several dates, including 4/3/24, 4/5/24, 4/8/24, 4/10/24, 4/22/24, and 4/24/24, the required assessments and documentation were not completed. The resident was admitted to the hospital on 4/8/24 due to a clot in the dialysis fistula, and upon returning to the facility on 4/10/24, no assessment of the fistula was recorded. The resident experienced significant bleeding from the fistula on 4/11/24, which was not promptly addressed due to the lack of ongoing monitoring and documentation by the facility staff. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other staff members revealed that the facility's expectations for monitoring and documenting the dialysis fistula were not consistently met. Staff members acknowledged the importance of completing the dialysis communication forms and conducting thorough assessments but admitted that these tasks were not always performed. The facility's education on dialysis care was described as primarily web-based, with some staff indicating that they had received limited training on the specific requirements for monitoring dialysis fistulas.
Failure to Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was assessed to identify triggers that could potentially re-traumatize the resident. Resident #72, who has a history of trauma related to verbal and physical abuse, was admitted with diagnoses including unspecified dementia, anxiety, and PTSD. The resident's care plan included general interventions for trauma but did not specify any triggers that could re-traumatize the resident. The Social Services Director admitted that they did not ask the resident or her daughter about specific triggers during the initial assessment. During interviews, the Social Services Director acknowledged the oversight and stated that triggers should have been identified and documented. The Director of Nursing was not well-versed in Trauma Informed Care and relied on the Social Services Director for information. The Nursing Home Administrator stated that the Social Services Director would reassess all residents with PTSD to update their care plans and provide staff education on trauma-informed care. The facility's policy on Trauma Informed Care mandates the identification of triggers to minimize re-traumatization, which was not followed in this case.
Failure to Ensure Competency of Private Caregiver
Penalty
Summary
The facility failed to ensure that a private caregiver for a resident had the necessary competencies and skills to provide appropriate care. The resident, who had been admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was being cared for by a private caregiver who was not formally trained as a Certified Nursing Assistant (CNA) or nurse. The private caregiver was performing activities of daily living (ADL) care such as transferring the resident to the bathroom, giving showers, and dressing the resident, without any formal training or oversight from the facility staff. The caregiver reported that she had to perform these tasks because the facility staff were slow to respond to call lights and had indicated that other private caregivers were providing care, so she could too. Facility staff, including CNAs and the Director of Nursing (DON), were either unaware of the private caregiver's involvement or assumed that the caregiver was competent without verifying her qualifications or providing necessary training. Interviews with the Nursing Home Administrator (NHA) and the DON revealed that they were not fully aware of the extent of the private caregiver's involvement in providing ADL care. The NHA acknowledged that the private caregiver was working outside her scope and that the facility staff should be providing the care. The private caregiver was subsequently educated that her role was limited to companionship and light domestic services, and that the facility staff were responsible for all ADL care. The resident's family member also expressed concerns that the private caregivers were providing hygiene care because the facility staff were not fulfilling their responsibilities. This situation highlighted a significant lapse in ensuring that caregivers had the appropriate competencies and skill sets to meet the resident's care needs.
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 356 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — 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 Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinellas Point Nursing And Rehab Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Bay Pointe Nursing Pavilion | 2.4 mi | ★★★★★ | 2 | 0 |
| Addington Place At College Harbor | 2.9 mi | ★★★★★ | 0 | 0 |
| South Heritage Health & Rehabilitation Center | 3 mi | ★★★★★ | 9 | 0 |
| Alpine Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westminster Suncoast.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.