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 Winkler Court during CMS and state inspections, most recent first.
A resident with Type 1 DM and a recent DKA history developed worsening hyperglycemia, emesis, confusion, and altered mental status, but critical labs showing glucose 592 and CO2 <5 were not promptly communicated or acted on. Staff documented elevated blood sugars and symptoms, yet provider notification and 911 activation were delayed until the resident was critically ill with suspected DKA and severe metabolic acidosis, requiring EMS transfer to the ER.
A resident who was Medicaid pending had a spouse who paid funds toward the resident’s stay with the understanding that the amount would be refunded once Medicaid was approved. After the resident died and Medicaid coverage was established, the Business Office Manager confirmed that no balance was owed and that a refund was due, but the refund was processed through the corporate office and was not issued within the required timeframe. The spouse reported not receiving the $1,546.00 refund and stated she was repeatedly given excuses, while facility records showed the amount as a paid voucher, demonstrating a failure to timely refund resident funds as required by policy and regulation.
A nurse prepared and handed a cup containing multiple oral medications to a resident, then left the room without observing ingestion, contrary to facility policy requiring meds to be administered at the time of preparation and the resident to be observed until the dose is fully taken. Later observation found the full medication cup and an additional pill still on the bedside table, while the RN initially claimed the resident had swallowed all medications before ultimately acknowledging that she had not ensured ingestion.
Surveyors found multiple areas of disrepair and uncleanliness, including cracked walls, missing or broken closet doors, broken blinds, peeling cove base, and dirty dining room cabinets with food debris. Staff and residents reported that maintenance concerns had been known for months but were not addressed, and documentation showed that necessary repairs were not completed despite being reported. Residents expressed discomfort and dissatisfaction with the living environment, and staff confirmed ongoing issues with cleanliness and maintenance.
Several residents, including those with dementia and physical limitations, were served milk during in-room meal service without being provided glasses, cups, or straws, requiring them to drink directly from the carton. In some cases, milk cartons were not opened for residents unable to do so themselves, and one unresponsive resident was left with an uncovered tray and no assistance for an extended period. Staff acknowledged the lack of proper utensils and the need to improvise with straws.
The facility did not ensure that the required Florida DNR forms were signed by a physician in a timely manner for three residents who had chosen DNR status. In each case, although the residents or their representatives signed the forms, the physician's signature was missing, and the forms were not properly filed in the medical record as required.
Staff failed to consistently follow infection prevention protocols, including Enhanced Barrier Precautions, for several residents with wounds and indwelling devices. Gowns were not worn during high-contact care activities, PPE was not always accessible, and required audits were missed. Additionally, drainage bags were improperly positioned, and PICC line dressings were not changed as ordered, with documentation not matching observed evidence. These lapses in infection control practices were confirmed through staff interviews and direct observation.
A resident with multiple pressure injuries did not have an updated care plan reflecting new wounds, and staff failed to implement or communicate appropriate interventions such as repositioning and offloading. Staff interviews revealed inconsistent understanding of pressure injury protocols, and significant changes in wound status were not reported to clinical leadership or the physician.
A resident with multiple medical conditions and pressure wounds did not receive an accurate skin assessment upon admission, with subsequent weekly assessments revealing wounds that were not initially documented. Staff used a tablet app for wound assessment but reported inconsistencies in measurement and staging, and the care plan was not updated to reflect new findings. Leadership and medical providers were not consistently informed of wound changes, and staff lacked formal wound staging training.
A resident with a history of schizoaffective disorder experienced a return of serious mental illness after a reduction in antipsychotic medication, leading to escalating behavioral disturbances and a physical altercation. Despite these changes and a re-diagnosis of schizophrenia, the facility did not initiate a PASRR Level II referral, and the process for reassessment after the reemergence of mental illness was not addressed in facility policy.
A resident's request and physician's order for DNR status were not reflected in the care plan, which continued to indicate Full Code. Despite documentation and communication of the resident's wishes, nursing staff did not update the care plan accordingly.
A resident with dementia and cognitive impairment did not receive individualized activities as outlined in their care plan. Over multiple days, the resident was not offered activity materials, music, television, or staff-led engagement, and there was no documentation of activity participation or refusals. Staff interviews confirmed insufficient stimulation and a lack of direct engagement by the activities department.
A resident's spouse was allowed to administer medications without a physician order, assessment, or documentation, contrary to facility policy. Staff provided the spouse with the resident's medications and sometimes did not supervise administration, while nurses signed the MAR as if they had given the medications themselves. The resident had multiple diagnoses and required assistance, and the DON was unaware of the practice.
A resident with glaucoma and moderate cognitive impairment was left with broken glasses for months, despite expressing the need for repair or replacement. Staff were aware of the issue but did not follow facility policy to report or address the problem, and no follow-up was made for a scheduled eye care appointment.
A resident with multiple health conditions and high risk for skin breakdown developed new pressure wounds that were not identified at admission. Staff failed to consistently turn and reposition the resident, relying instead on offloading cushions, and did not provide adequate offloading for all affected areas. Wound assessments were not consistently performed or communicated, and significant changes in wound status were not reported to clinical leadership or the physician.
A resident with chronic kidney disease and other serious conditions did not consistently receive the ordered double portions of a therapeutic diet, especially during dialysis days. Staff failed to verify the contents of meals sent to the dialysis center, resulting in the resident experiencing hunger and not receiving adequate nutrition as prescribed.
Two residents experienced medication order discrepancies due to inadequate competency and documentation by nursing staff. One resident did not receive a prescribed daily hydrocortisone injection after hospitalization, as the facility administered only a one-time dose without proper documentation or notification. The facility's three-step medication review process was not documented. Another resident received an incorrect Gabapentin dosage due to entry errors and lack of physician notification. These incidents highlight a breakdown in medication reconciliation and adherence to facility policies.
Two residents experienced significant medication errors due to improper transcription and verification of hospital discharge orders. A resident with adrenal insufficiency did not receive prescribed daily hydrocortisone, leading to hospitalization. Another resident received incorrect Gabapentin dosage for several days. The facility's medication reconciliation process failed, with no proper documentation or physician notification.
Delayed Response to Critical Hyperglycemia and Suspected DKA
Penalty
Summary
The facility failed to ensure that a resident with Type 1 diabetes was free from neglect when staff did not recognize, act upon, and report a critical change in condition in a timely manner. The resident had been admitted with a diagnosis of Type 1 Diabetes and had a recent hospital history of diabetic ketoacidosis (DKA). Facility policy stated that STAT and critical labs must be called to the physician as soon as they result, with the nurse documenting the communication and follow-up in the medical record. On 4/23/26, the resident had multiple elevated blood glucose readings, including 439 at 8:39 a.m., 413 at 10:59 a.m., and 535 at 12:43 p.m. The record showed insulin was given after the first two readings, but there was no further documentation for insulin administration, resident assessment, or provider notification after the 12:43 p.m. glucose of 535, despite the sliding scale order to notify the provider for blood glucose levels over 450. The resident was also observed by the speech therapist that morning with emesis on herself and the floor, weakness, clamminess, slurred speech, reduced alertness, and difficulty responding to questions. The speech therapist reported the resident was not acting like her normal self and notified nursing staff. Critical lab results later showed a glucose of 592 and CO2 of less than 5, with the labs electronically faxed to the facility at 11:58 a.m. The change in condition form documented clinician notification at 2:00 p.m., and the provider note at 2:46 p.m. described the resident as critically ill with suspected DKA and severe metabolic acidosis and stated she was transferred emergently to the ER by EMS. EMS documented that the resident was hallucinating, somnolent, and increasingly confused, and noted no clear reason was provided for the delay in activating 911 after the confusion and persistent hyperglycemia were reported. Interviews with the APRN, DON, RN unit manager, speech therapist, and paramedic confirmed that the critical labs and change in condition were not communicated or acted on promptly.
Delayed Refund of Resident Funds After Medicaid Approval and Death
Penalty
Summary
The facility failed to ensure that all refunds due to a resident representative were issued within 30 days of discharge, as required by policy and regulation. The resident involved was admitted on an unspecified date and later expired at the facility. The resident’s spouse reported by telephone that the facility owed her a refund of $1,546.00 and that she had not yet received it, stating that the facility kept giving her excuses. The Business Office Manager (BOM) confirmed that the resident was Medicaid pending and that the resident representative had been responsible for paying $1,500.00, which was to be refunded once Medicaid was approved, and that the resident ultimately owed no money to the facility once Medicaid coverage began. The BOM stated that refunds are processed by the corporate office, not the facility, and attributed the delay to turnover in the corporate office, with each new staff member restarting the process. The BOM acknowledged that the refund, documented on an invoice as a voucher paid amount of $1,546.00 with payment status listed as “Paid,” was not issued within the required timeframe. This deficiency centers on the facility’s failure to comply with its own refund policy, which required refunds to be issued within the timeframe mandated by federal and/or state law, resulting in a delayed refund to the deceased resident’s spouse despite ongoing communication and confirmation that no balance was owed for the resident’s stay once Medicaid coverage was in place.
Medications Left Unattended at Bedside Without Ensuring Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with professional standards and the facility’s own medication administration policy. The policy required that medications be administered at the time they are prepared, by the same person who prepares them, and that residents be observed after administration to ensure the dose is completely ingested. During an interview and observation on 3/5/26 at 9:12 a.m., a medication cup containing seven pills and a separate large pink pill were observed on Resident #12’s bedside table, with no nurse present in the room. Resident #12 stated that the medications had been given to her, that she was supposed to take them, and that the nurse had handed them to her and then walked out. At 9:20 a.m., RN Staff A was observed at the medication cart and confirmed she had administered medications to Resident #12. When informed about the unattended pills, RN Staff A initially stated she had watched the resident take the whole cup and swallow the medications. At approximately 9:23 a.m., when RN Staff A and the surveyor returned to Resident #12’s room, the medication cup with the seven pills and the pink pill were still on the bedside table. RN Staff A questioned the resident about not taking the medications and then acknowledged she had given the medications and left the room without ensuring they were ingested, stating she knew this was wrong. These observations and interviews demonstrate that the nurse did not follow the facility’s policy or accepted professional standards for medication administration.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment for residents, staff, and the public, as evidenced by multiple observations of disrepair and uncleanliness throughout the memory care unit and other areas. Surveyors observed cracked walls with exposed plaster, missing or broken closet doors, broken window blinds, peeling cove base, cracked and stained floors, missing bathroom tiles, and a sink separated from the wall. Additionally, foam was sprayed in a window corner, and a chair/bed rail was missing from a wall. The dining room cabinets were found to contain ground-in dirt, food debris, and trash, with the Director of Housekeeping acknowledging that cleaning had been missed and that such conditions could attract pests. The Administrator confirmed awareness of ongoing pest issues and agreed that the unit required updates. Further observations included a urinal stored on a bathroom handrail without resident identification, a bathroom door missing a doorknob, and a soiled privacy curtain with brown stains. Several rooms had broken or missing blinds and closet doors, with residents reporting that these issues had persisted for months. One resident expressed discomfort due to a bed that was too short, and staff confirmed that maintenance concerns had been reported but not addressed. Documentation showed that while quotes for supplies had been obtained, no orders had been placed for necessary repairs, and work orders were marked as completed despite the issues remaining unresolved. Interviews with staff, including LPNs, the ADON, the Regional Nurse Consultant, and the DON, confirmed awareness of the deficiencies, such as broken blinds and missing closet doors, but also revealed a lack of follow-through in addressing these concerns. Residents reported dissatisfaction with the state of their rooms, including missing closet doors that left their clothing exposed. The facility's own policy required work orders to be completed with priority, but evidence showed that repairs were not made in a timely manner, contributing to an environment that was not safe, clean, or comfortable for residents.
Failure to Provide Dignified Meal Service During In-Room Tray Administration
Penalty
Summary
During multiple observations of in-room meal tray service, five residents were not treated with respect and dignity as required. Residents with various diagnoses, including polyarthritis and dementia, were served milk without being provided glasses, cups, or straws, requiring them to drink directly from the carton. In several instances, milk cartons were not opened for residents who were unable to do so themselves, and one resident, who was unresponsive to verbal stimuli, was left with an uncovered tray and no assistance for 14 minutes. Staff interviews confirmed awareness of the issue, noting that the kitchen did not send cups and that staff had to find straws for residents to drink their milk.
Failure to Obtain Timely Physician Signature on Florida DNR Orders
Penalty
Summary
The facility failed to ensure that the physician signed the State of Florida Do Not Resuscitate (DNR) order in a timely manner for three residents who had chosen DNR status. In each case, although the residents or their representatives expressed their wishes and, in some instances, signed the state-specific yellow DNR form, the required physician signature was not obtained promptly. For one resident, a DNR order was initiated and documented in the medical chart, but the corresponding Florida DNR form was not signed by the physician. Staff interviews revealed that the care plan was not updated, and the state-specific form was not signed by either the resident or the physician until much later. For two other residents, the state-specific DNR forms were signed by the residents or their responsible parties, but the forms were not present in the medical chart as required and were later found unsigned in the physician's folder. The Director of Nursing confirmed that the Florida DNR form is necessary for resident transport and should be signed by both the resident and physician and placed in the chart. The facility's failure to obtain timely physician signatures on the DNR forms resulted in incomplete documentation of residents' advance directives.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program (IPCP) for multiple residents, as evidenced by direct observations, interviews, and record reviews. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling devices, or those at risk for multidrug-resistant organisms (MDROs). For example, staff were observed providing care to residents on EBP without donning gowns, despite facility policy and posted signage requiring gown and glove use during high-contact care activities. In the Memory Care Unit, gowns were not available in designated storage areas, and daily PPE audits were not consistently performed. Staff interviews revealed gaps in knowledge and inconsistent adherence to EBP protocols, with some staff only using gowns for specific conditions like scabies, and others citing lack of PPE accessibility as a barrier to compliance. Additional deficiencies were identified in the management of indwelling catheter and vascular access devices. One resident with bilateral nephrostomy tubes was observed with drainage bags improperly positioned—one on the floor and another under the pillow—contrary to facility policy requiring drainage bags to be kept off the floor and below bladder level. Staff interviews confirmed awareness of the correct procedure, but the practice was not followed. Another resident with a PICC line had a dressing that had not been changed in accordance with the facility's policy and physician orders, with the dressing date indicating it had not been changed since hospital admission. Documentation in the Medication Administration Record (MAR) did not match physical evidence, and the DON was unable to provide proof of dressing changes as required. Further, staff were observed providing urinary catheter care and changing adult briefs for a resident with multiple indwelling devices and wounds without wearing gowns, despite clear signage and policy requirements. The RN Unit Manager did not intervene when observing this non-compliance. Staff interviews indicated that the omission was due to being in a hurry, and there was a lack of consistent understanding and enforcement of PPE protocols. These failures in infection control practices placed residents at risk for the transmission of MDROs and did not align with the facility's stated IPCP policies.
Failure to Update Care Plan and Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for a resident with multiple pressure injuries, including a Stage 2 flank wound and a Stage 3 coccyx wound, which were not identified in the admission assessment. Weekly skin assessments later documented these wounds, but the care plan did not reflect goals or interventions for their management. There was also no documentation of communication regarding the new pressure injuries in the dialysis communication binder, and staff interviews revealed inconsistent understanding and implementation of repositioning and offloading protocols. The resident, who was cognitively impaired and dependent on staff for care, was observed without appropriate offloading devices and was not repositioned as needed, despite being at high risk for pressure injuries. Further observations and interviews indicated that staff, including CNAs and therapy personnel, believed that repositioning was unnecessary if an offloading cushion was used, and there was no scheduled turning program in place. The DON and Risk Manager confirmed the absence of a formal turn and reposition policy, and the wound care team had not reported significant changes in the resident's wound status, such as the presence of black tissue. The resident's physician and physician's assistant were not aware of the wound's progression, as they relied on nursing staff for updates, which were not provided. Photographic evidence was obtained to support these findings.
Failure to Ensure Accurate Assessment and Documentation of Pressure Wounds
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident with multiple complex medical conditions, including end stage renal disease, diabetes, cognitive impairment, and multiple pressure wounds. Upon admission, the resident's skin assessment did not document wounds on the coccyx or right flank, and the Minimum Data Set (MDS) did not reflect the presence or stage of these pressure injuries. Subsequent weekly skin assessments identified new wounds that were not present in the initial assessment, and the care plan was not updated to include these findings as of several days later. Observations revealed the resident was often found lying in bed with heels directly on the mattress and without appropriate offloading devices for pressure wound prevention. Interviews with nursing staff indicated that wound assessments were performed using a tablet application, but staff acknowledged that the accuracy of wound measurements and documentation could be compromised by user technique. There was inconsistency in wound staging and documentation, with discrepancies noted between staff descriptions and electronic records, including conflicting reports of wound characteristics such as the presence of slough or eschar. Further interviews with facility leadership and external vendors revealed a lack of formal wound staging training for staff, with education being provided by a dressing supply vendor who did not directly train staff on staging. The risk manager and DON were unaware of certain wound developments, and the resident's physician and physician assistant had not been informed of significant changes in the resident's wound status. The dressing supply vendor clarified that she only provides suggestions and does not assess or stage wounds, and had not observed staff performing wound assessments in several months.
Failure to Complete PASRR Level II Referral After Return of Serious Mental Illness
Penalty
Summary
The facility failed to complete a PASRR Level II referral for a resident who experienced a return of serious mental illness after admission. The resident, with a history of schizoaffective disorder, was initially determined not to require specialized services following a PASRR Level II assessment. After a psychiatric evaluation considered the disorder resolved, a gradual dose reduction of antipsychotic medication was initiated. Despite ongoing antipsychotic use and cognitive impairment, a significant change in status MDS assessment did not indicate the presence of serious mental illness. Over the following weeks, the resident exhibited escalating behavioral changes, including agitation, verbal outbursts, territorial guarding, and physical aggression, culminating in an incident where the resident physically assaulted a roommate. Subsequent psychiatric evaluation confirmed the return of psychotic symptoms and resulted in a re-diagnosis of schizoaffective disorder. The resident's medication regimen was adjusted, and the diagnosis list was updated to reflect active schizophrenia. Observations documented ongoing behavioral disturbances, and staff interviews confirmed increased aggression and territoriality, particularly after the medication dose reduction. The facility's policy did not address the process for PASRR assessment following the reemergence of serious mental illness post-admission, and there was no documentation of a PASRR Level II referral being initiated or completed after the resident's condition changed.
Failure to Update Care Plan to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to develop a comprehensive care plan that accurately reflected a resident's choice regarding code status. Although a physician's order and nursing progress note documented the resident's request for Do Not Resuscitate (DNR) status, the care plan continued to indicate Full Code status, which would require initiation of CPR. Interviews with the resident confirmed she had communicated her desire for DNR status to the facility. Both the RN and Unit Manager acknowledged that the care plan was not revised to reflect the resident's wishes, and the Director of Nursing confirmed that the care plan should have been updated at the time of the resident's request. This deficiency was identified for one resident whose advanced directives were not accurately documented in the care plan, despite clear communication and documentation of the resident's wishes and physician's orders.
Failure to Provide Individualized Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide activities designed to meet the interests and well-being of a resident with dementia and cognitive impairment. The resident's care plan included goals for daily participation in activities of choice, with interventions such as encouraging engagement in general activities and providing in-room activities if preferred. However, over several days of observation, the resident was not offered any activity materials, music, television, or staff-led activities, except for a Daily Chronicle paper at the bedside. There was no documentation of activity refusals or participation in any activities for the past 30 days. Interviews with staff revealed that the resident expressed interest in watching TV but did not have access to a TV remote, and staff acknowledged that the resident was not receiving enough stimulation. The Director of Activities had not personally engaged the resident, and activity documentation was lacking. The Social Services Director indicated that interventions for loneliness or withdrawal would involve family and interdisciplinary team input, but there was no evidence of such actions for this resident. The lack of individualized activities and engagement was confirmed by multiple staff members and through record review.
Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and facility policy for one resident. Staff allowed the resident's spouse to administer medications without a physician order, assessment of the spouse's capability, or documentation in the care plan. The spouse reported that he was given the resident's medications by staff and administered them without supervision, and there was no evidence that the physician was notified or that the spouse was properly trained. Staff interviews confirmed that the resident would only take medications from her husband, and that nurses provided the medications to him, sometimes without remaining present to ensure administration. The Medication Administration Record was signed by nurses as if they had administered the medications themselves. The resident involved had diagnoses including protein calorie malnutrition, convulsions, muscle weakness, and required assistance with personal care. The spouse reported concerns about medication administration practices, including medications being given on an empty stomach, a double dose of Keppra, and a missing dose of Eliquis. The Director of Nursing was unaware that the spouse was administering medications and confirmed there was no assessment or documentation to support this practice. Facility policy required medications to be administered by authorized personnel and in accordance with prescriber orders, which was not followed in this case.
Failure to Assist Resident with Vision Services and Glasses Repair
Penalty
Summary
The facility failed to assist a resident in obtaining necessary vision services and in ensuring that the resident's glasses were in good repair. The resident, who had diagnoses including type 2 diabetes mellitus, hemiplegia, and glaucoma, was observed multiple times wearing broken bifocal glasses missing the left arm of the frame. Despite the resident expressing a desire for new or repaired glasses, no action was taken to address the issue. Staff interviews revealed that the resident's glasses had been broken for months, and although the care plan instructed staff to report any damage to glasses, neither the Director of Nursing nor the Social Service Director were aware of the problem. The process for addressing vision concerns was not followed, as staff failed to notify the appropriate personnel or initiate the required documentation for repair or replacement. Additionally, the facility did not follow up on a physician's order for an eye care visit scheduled six months after the last consultation, and there was no documentation of any subsequent appointment or evaluation. The resident's cognitive skills were noted as moderately impaired, further emphasizing the need for staff assistance in managing vision care. The facility's policy required prompt referrals and assistance with appointments for vision and hearing services, but these procedures were not implemented for this resident, resulting in an unresolved deficiency.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple comorbidities, including end stage renal disease, diabetes, cognitive impairment, and immobility, was admitted to the facility with a high risk for skin breakdown and existing pressure wounds. Initial assessments did not identify wounds on the coccyx or right flank, and the admission MDS did not document the presence of stage 3 or unstageable pressure injuries, nor did it include interventions such as pressure-reducing devices, a turning/repositioning program, or nutrition/hydration measures. However, within days, new wounds were identified, including a stage 2 wound on the right rear flank and a stage 3 wound on the coccyx, which were not present or documented at admission. Observations and interviews revealed that the resident was not consistently turned or repositioned, especially while in bed or in a wheelchair, despite being at high risk for pressure injuries. Staff, including CNAs and therapy personnel, expressed a belief that offloading cushions alone were sufficient and that repositioning was not necessary when such devices were used. There was no scheduled turning or repositioning program in place, and the care plan only included general interventions such as turning and repositioning as needed. The resident was observed sitting on an obstructed offloading cushion and without offloading support for the right flank wound, and staff confirmed that no specific offloading or repositioning was provided for that area. Further, wound assessments were inconsistent and not promptly communicated to clinical leadership or the physician. The presence of black tissue in the right flank wound, indicating an unstageable wound, was not documented as a significant change in condition, and neither the physician nor the physician's assistant were made aware of this development. The wound team had not seen the wound for at least a week, and there was a lack of clear communication and documentation regarding the resident's wound status and necessary interventions.
Failure to Provide Ordered Therapeutic Diet for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, diabetes, anemia, heart failure, chronic ulcers, and kidney failure, was not consistently provided with the ordered therapeutic diet. The resident, who is cognitively intact and attends dialysis three times per week, reported feeling extremely hungry after returning from dialysis. Staff interviews and record reviews revealed that although the resident was supposed to receive a chronic kidney disease diet with extra portions, there was a lack of clarity and follow-through regarding the contents and adequacy of the meals provided, particularly the lunch sent to the dialysis center. Observations showed that the resident's lunchbox sometimes contained only a sandwich, crackers, and an empty water bottle, which did not meet the ordered double portions. The kitchen manager admitted to not verifying the contents of the lunchboxes beyond checking their weight and did not open them to ensure accuracy. Both the dietician and kitchen manager were unaware of the resident's complaints of hunger and only realized after review that the resident should have been receiving additional food items. This failure to provide the prescribed therapeutic diet led to the resident experiencing hunger and not having his nutritional needs met as ordered.
Medication Order Discrepancies Due to Inadequate Competency and Documentation
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to provide appropriate nursing and related services, as evidenced by medication order discrepancies for two residents. For the first resident, after returning from hospitalization, the discharge orders included a daily intravenous hydrocortisone injection. However, the facility administered only a one-time intramuscular dose and discontinued the daily order without proper documentation or notification to the Advanced Registered Nurse Practitioner (ARNP) or physician. The ARNP was unaware of the hospital's daily steroid order and did not discontinue it, indicating a lack of communication and documentation. The Director of Nursing (DON) described a three-step medication review process involving initial review, a 24-hour chart check, and a morning meeting review. However, for the first resident, the DON could not provide documentation that these steps were completed, as the 24-hour chart check and admission checklist were missing, and the Medication Review Report was unsigned by the provider. This lack of documentation and verification contributed to the oversight in medication administration. For the second resident, the hospital discharge orders included a specific dosage of Gabapentin, but the facility entered and administered an incorrect dosage for several days. The error was eventually corrected, but there was no documentation of physician notification or discussion regarding the dosage change. The DON acknowledged that the error was due to incorrect entry by the RN Unit Manager and a failure to identify the mistake during the second check by the weekend supervisor. This incident highlights a breakdown in the medication reconciliation process and a failure to adhere to the facility's policy on event reporting and physician notification.
Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of medications for two residents. Resident #1, who had a history of adrenal insufficiency, was discharged from the hospital with an order for daily intravenous hydrocortisone. However, upon readmission to the facility, the order was incorrectly transcribed as a one-time intramuscular injection, and the daily administration was discontinued without proper documentation or physician notification. This error led to a significant decline in Resident #1's condition, resulting in hospitalization for adrenal insufficiency due to corticosteroid withdrawal. Resident #2 was admitted with a hospital order for Gabapentin 200 mg twice daily, but the facility entered the order incorrectly as 100 mg twice daily. This error persisted for several days until it was corrected, but there was no documentation of physician notification or discussion regarding the dosage change. The Director of Nursing (DON) was unaware of the discrepancies until the survey, indicating a lapse in the facility's medication reconciliation and verification processes. The facility's policies for physician orders and event reporting were not followed, as evidenced by the lack of documentation and failure to complete the required checks and verifications. The DON and staff involved did not ensure that the medication orders were accurately entered and reviewed, leading to significant medication errors for both residents. The facility's process for medication reconciliation, particularly for residents returning from hospital stays, was inadequate, resulting in these deficiencies.
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Illustrative
What surveyors actually found near you
We read the 100 citations issued within 25 miles in the last 12 months — including the 11 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Myers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire At Evans | 2.3 mi | ★★★★★ | 4 | 0 |
| Lee Memorial Hospital Skilled Nursing Unit | 2.4 mi | ★★★★★ | 0 | 0 |
| Page Rehabilitation And Healthcare Center | 3.5 mi | ★★★★★ | 8 | 0 |
| Cedarbrook Health And Rehabilitation Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Fort Myers Rehabilitation And Nursing Center | 4.9 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 July 2026) and official state health department websites.