Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Florence Park Care Center during CMS and state inspections, most recent first.
Infection control failures involved shared glucometers, EBP, catheter care, laundry handling, and water management. An RN used a contaminated glucometer on two residents without cleaning it or performing hand hygiene, and an LPN used the wrong disinfectant and placed the device next to clean supplies. Staff also failed to follow EBP for residents with a PICC, dialysis access, and an open wound, a catheter bag was observed dragging on the floor, soiled laundry was moved through clean areas, and the facility lacked a documented Legionella WMP.
Controlled substance documentation was inaccurate and often completed late when nursing staff failed to sign out narcotic medications at the time of removal and MAR times did not match IPCSAR entries. Multiple residents received scheduled meds, including gabapentin, lorazepam, morphine, hydrocodone-acetaminophen, and clonazepam, outside the ordered administration window, with some doses documented hours late or without a corresponding IPCSAR entry. An LPN was observed completing narcotic sign-out after the med had already been given, and staff interviews confirmed the expected process was real-time documentation and timely administration.
The facility failed to sustain its QAPI/QAA process for monitoring narcotic sign-out sheets and timely pain medication administration. An LPN did not sign out a controlled medication when it was removed, and review of IPCSARs showed repeated failures to document controlled substance removal and administration at the time of removal for all sampled residents. Four residents ordered pain meds had multiple late administrations, sometimes more than 3 hours past the scheduled time, and the QAPI committee discussions and audits did not identify or correct the ongoing documentation and timing issues.
Delayed Administration of Ordered Pain Medications: Surveyors found that ordered pain meds were not given on time for multiple residents with chronic pain and opioid use. MAR review showed repeated late doses of gabapentin, pregabalin, oxycodone-acetaminophen, and Norco, sometimes by several hours. Residents reported that late administration caused pain to return or worsen, and staff attributed the delays to call-offs, interruptions, and late medication cart coverage. The DON, Medical Director, and Administrator stated meds were expected to be administered per physician orders and facility policy.
Improper Medication Storage and Labeling: The facility failed to properly store, label, and secure medications in 2 of 3 med rooms. Surveyors observed medications brought in from other facilities commingled with clean supplies and overstock meds in Unit A and Unit B med rooms. An opened TB serum bottle and an opened insulin pen were not dated, and the insulin pen lacked a pharmacy label with the resident's name and directions. The DON stated the facility did not keep records of discontinued meds unless controlled and expected staff to date opened meds and ensure pharmacy labels were present.
The facility failed to support resident self-determination and dignity for two residents. One resident with intact cognition and a care plan need for assistance with lower body dressing was repeatedly observed without pants after incontinent episodes, stated he wanted pants, and said staff told him he had none; staff admitted they did not ask his preference or offer alternative coverings. The report also identifies a second cognitively intact resident, but the narrative is cut off before the full details are provided.
A resident with COPD, schizoaffective disorder bipolar type, and depression was observed wearing the same stained shirt and pants on multiple days, and the resident’s room had spilled food and scattered items on the floor while an untouched breakfast tray remained on the bedside table. The resident’s family member reported concerns to staff, and an LPN, STNA, DON, and Administrator all stated residents were expected to have clean clothing daily and a clean, home-like environment.
Failure to provide written transfer and bed hold notices: Two residents with intact cognition and significant medical histories, including dementia, CKD, and acute kidney failure, were transferred to the hospital, but the facility did not consistently notify the resident’s representative in writing of the bed hold notice, transfer/discharge, or reasons for the move in a language and manner they could understand. Staff interviews showed the BOM handled notices inconsistently, the DON said nursing did not complete the notifications, and the Administrator expected the notices to be sent and documented.
A resident with dysphagia, malnutrition, hemiplegia, and severe cognitive impairment had a care plan for tube feeding and a physician order for Two-Cal HN at 50 mL/hr continuous, but observations showed the enteral feeding infusing at 65 mL/hr while the container was labeled for 50 mL/hr. Staff interviews confirmed the expectation to follow the care plan and physician orders for nutrition, and the Medical Director stated that over-infusion of enteral feeding could cause aspiration risk, nausea, vomiting, and/or diarrhea.
A resident with severe cognitive impairment and total dependence for transfers was supposed to use a Hoyer lift for all transfers per the care plan, PT, physician orders, and STNA Kardex. Staff instead used a sit-to-stand lift during a transfer, and the resident slid out of the chair onto the floor. Family and staff stated the wrong lift was used, while the DON and Administrator stated staff were expected to follow the Hoyer lift orders.
Incorrect Enteral Feeding Rate: A resident with dysphagia, malnutrition, and severe cognitive impairment had a g-tube feeding order for Two-Cal HN at 50 mL/hr, but observations showed the pump infusing at 65 mL/hr on two occasions while the container was labeled for 50 mL/hr. An LPN stated she had not checked the pump or seen the resident at the start of shift, and leadership stated staff were expected to verify and follow the physician’s orders for tube feeding.
Incomplete dialysis communication and documentation affected two residents receiving HD. One resident had severe cognitive impairment and the other was cognitively intact, but both had HD orders and care plans while the facility’s Dialysis Center Communication Records were incomplete or missing for multiple visits. Staff and the dialysis center reported that the required forms were rarely returned, and the DON confirmed no HD communication forms were available in medical records.
The facility failed to maintain an effective pest control program and was not free of gnats. A resident with COPD, schizoaffective disorder, and anxiety had gnats observed on the resident, in the room, and around nebulizer parts on multiple occasions, while another resident with heart failure and dementia was observed eating lunch with multiple gnats flying around and landing on the food tray. Staff, the DON, and the Administrator stated gnats in resident rooms did not meet the expectation of a home-like environment, and the pest control company reported the facility had not made it aware of the gnat issue.
A failure to safeguard and account for controlled substances led to the diversion of narcotic pain medications by an LPN, resulting in three residents with chronic pain conditions not receiving their prescribed doses. These residents experienced unmanaged pain, with no documented pain assessments or provider notifications, and staff failed to follow facility policies for medication administration and pain management.
A facility failed to ensure proper control and documentation of controlled substances when an LPN administered medications to several residents but did not sign the controlled medication records at the time of administration, instead completing the documentation later in front of a surveyor. The residents involved had various medical conditions and were prescribed controlled medications such as gabapentin, pregabalin, morphine, oxycodone, and lorazepam. Facility policy required real-time documentation and shift-to-shift reconciliation, but these procedures were not followed, as confirmed by staff interviews and record reviews.
QAPI oversight failed to sustain monitoring of narcotic sign-out documentation and timely pain medication administration. An LPN did not sign out a resident’s controlled medication when it was removed, and review of IPCSARs showed repeated failures to document controlled substance removal at the time of administration for all sampled residents. Four residents who were care planned for pain meds had multiple late doses, sometimes more than three hours past the scheduled time, and they reported worsening pain. The DON stated audits were limited to live observations and did not compare IPCSARs with the MAR, while the QAPI committee discussed the concerns but did not identify the ongoing discrepancies.
The facility failed to maintain complete refrigeration temperature logs, missing entries for eight days in October. Staff interviews revealed the Dietary Supervisor forgot to record temperatures due to covering multiple shifts, risking food spoilage and bacterial growth.
The facility failed to label medications according to professional standards and ensure they were used before expiration. Observations revealed expired and undated medications on C1 and C2 Hall carts. Staff interviews confirmed the responsibility to check and label medications, with risks of decreased effectiveness noted.
The facility failed to serve hot food at a proper temperature, as scrambled eggs were found to be below the expected temperature during a test tray evaluation. Staff interviews revealed issues with the warming process, and a resident expressed dissatisfaction with cold food. The facility's policy requires hot foods to be served as hot as safely possible, but this standard was not met.
The facility failed to follow infection control policies, risking healthcare-associated infections for two residents. An LPN did not perform hand hygiene or use gloves during medication administration, and an Activity Assistant handled food without washing hands or using gloves. Additionally, soiled meal trays were improperly managed in the C Unit/COVID Unit kitchenette, raising concerns about cross-contamination.
Infection Control Failures With Glucometer Use, EBP, Catheter Care, Laundry, and Water Management
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for multiple residents and for all current residents. The report identified failures related to blood glucose monitoring, enhanced barrier precautions, catheter care, laundry handling, and the absence of a documented water management plan for Legionella. The deficiency was cited at 42 CFR 483.80 with Immediate Jeopardy determined on 01/13/2026. The facility also had policies in place for standard precautions, glucometer cleaning, enhanced barrier precautions, catheter care, general infection control, and laundry handling, but staff actions did not follow those requirements. During observation, RN4 performed blood glucose monitoring for R70 and then used the same shared glucometer on R67 without cleaning or disinfecting it between residents. RN4 placed the glucometer on a treatment cart without a barrier, did not clean it after use, and did not perform hand hygiene after removing gloves. RN4 then attempted to use the contaminated glucometer for another resident before being stopped. Later, LPN6 performed a blood glucose check on R41, placed the glucometer on the bedside table without a clean barrier, and after the check cleaned it with a Sani-Cloth wipe that was not the facility-designated disinfectant for the glucometer. LPN6 then placed the wrapped glucometer on the medication cart next to clean supplies and failed to perform hand hygiene before moving to another resident. The report also documented failures with enhanced barrier precautions. RN7 entered R67's room, which was designated for EBP due to a PICC line, and changed the PICC dressing without gown, gloves, or a mask. For R129, who had a dialysis access port and an order for EBP, there was no EBP signage posted and no PPE supplies in the room. For R81, who was on EBP for an open wound, an STNA changed the resident's brief wearing gloves only and left without hand hygiene, and an LPN provided medication and hydration care, touched the bed linens, and exited without hand hygiene before handling the medication cart and computer. The report further noted that R8's indwelling urinary catheter collection bag was dragging on the floor while the resident was in the hallway. In addition, the laundry room observation showed soiled laundry carts being moved through the same doorway and work area used for clean laundry, clean and soiled items were not separated as required, and impervious gloves, impervious gowns, and disinfectant supplies for reusable PPE were not available. The facility's water management binder did not contain a Legionella policy, a documented water management plan, evidence of a water management team, or documentation of periodic team meetings.
Controlled Substance Documentation and Timely Medication Administration Failures
Penalty
Summary
The facility failed to ensure controlled substances were documented and reconciled in accordance with policy and professional standards when nursing staff did not sign out narcotic medications at the time they were removed from the bubble packs on the A, B, and C Hall medication carts. The controlled substance record sheets, titled Individual Patient Controlled Substance Administration Records (IPCSAR), frequently showed sign-out times that matched the ordered medication times rather than the actual removal times, and in multiple instances the IPCSAR entries did not correlate with the Medication Administration Record (MAR) administration times. The facility policy required controlled substances to be documented at the time of removal, including the date, time, and amount removed. Surveyors observed an LPN on the A Hall medication cart who did not sign out a resident’s gabapentin dose when it was removed. The LPN later returned to the cart and stated the medication had already been administered and she was only then completing the sign-out documentation. Record review for multiple residents showed repeated late administrations and missing or inconsistent IPCSAR documentation. Examples included gabapentin, lorazepam, morphine sulfate, hydrocodone-acetaminophen, clonazepam, and other controlled medications being documented hours after the scheduled administration time, sometimes with no corresponding IPCSAR entry at all. In several cases, doses were given outside the facility’s one-hour medication administration window, and the MARs did not contain notes showing the physician was notified. The affected residents included individuals with chronic pain, anxiety, COPD, ESRD, traumatic brain injury, hemiplegia, dementia, Alzheimer’s disease, Parkinson’s disease, and other conditions. Several residents had cognitive impairment ranging from moderate to severe, while others were cognitively intact and reported frequent pain or delayed medication administration. One resident stated pain medications were often not given on schedule and that delayed doses worsened pain. Interviews with nursing staff, the nurse supervisor, the DON, the administrator, and the contracted pharmacist confirmed that controlled substances were expected to be signed out when removed, administered on time, and documented accurately, but the DON stated she had reviewed only a limited sample of IPCSAR sheets and had not reconciled them with MAR administration times.
QAPI Oversight Failed to Sustain Narcotic Documentation and Pain Medication Monitoring
Penalty
Summary
The facility failed to implement and sustain its Plan of Correction related to monitoring narcotic sign-out sheets and timely administration of pain medications. The QAPI/QAA process was not thoroughly performed, and the QA/QAPI Committee did not provide effective oversight or follow-up of identified concerns. The facility’s QAPI policy stated it would maintain an ongoing, facility-wide, data-driven program to improve resident care, and the PoC required the DON to monitor controlled substance administration records from each medication cart and to audit pain assessments and staff documentation. During observation of the A Hall medication cart, an LPN did not sign out a resident’s 8:00 AM gabapentin dose when it was removed from the bubble pack. The LPN later returned to the cart and stated the medication had been administered at 10:20 AM and that she was only then completing the required sign-out documentation. Review of IPCSARs for the A, B, and C Hall medication carts showed a repeated pattern of nursing staff failing to accurately document controlled substance removal and administration, with sign-out times often reflecting the ordered time rather than the actual administration time documented on the MAR. Across the survey, the controlled narcotic record sheet was not completed at the time of removal for 11 of 11 sampled residents. Review of the records for four residents who were care planned for pain medication showed multiple instances in which pain medications were administered late, sometimes more than three hours past the scheduled time and outside the facility’s medication window, with residents reporting worsening pain. The QAPI Committee minutes showed discussion of deficiency tags, audit results, staff training, and the PoC related to narcotic medication administration and pain management, and the DON and Administrator stated audits were limited, did not reconcile IPCSARs with the MAR, and were not completed as scheduled during the holiday period. The Medical Director stated the committee discussed sign-in procedures, narcotic counts, pain assessments, timely administration of narcotic pain medication, and accurate narcotic documentation, and noted that late administration could affect pain relief and contribute to anxiety and behaviors.
Delayed Administration of Ordered Pain Medications
Penalty
Summary
The facility failed to have an effective system in place to ensure pain management was provided to residents who required such services. Surveyors found that pain medications were not administered timely in accordance with physician orders and the comprehensive care plans for 4 of 8 sampled residents: R68, R73, R122, and R127. Facility policies reviewed stated that pain management should be provided consistent with professional standards, care plans, and resident preferences, and that scheduled medications should be administered within one hour of the ordered time unless otherwise specified. R68 was admitted with diagnoses including ESRD, left ankle and foot pain, and shoulder pain. Her MDS indicated moderate cognitive impairment and that she had frequent pain and was taking opioids. Her care plan directed staff to administer analgesics as ordered. The MAR showed pregabalin and oxycodone-acetaminophen doses given well after the scheduled administration times, including doses more than one hour late and some several hours late. During interview, R68 stated her pain medications were frequently administered late and that delays caused her pain to return and made it harder for her symptoms to settle back to a tolerable level. R73 was admitted with chronic pain syndrome, peripheral vascular osteomyelitis, and peripheral disease. His MDS showed he was cognitively intact and had pain almost constantly, with opioid use for pain. His care plan directed staff to administer pain medications as ordered. The MAR showed multiple gabapentin doses given outside the scheduled time window, including doses more than two and three hours late. R73 stated his pain medications were often not given on schedule, that late doses intensified his pain, and that he often waited at least one hour past the scheduled time and sometimes two hours or longer. R122 was admitted with diagnoses including traumatic subdural hemorrhage, muscle wasting and atrophy, and chronic pain. Her MDS showed she was cognitively intact and had frequent pain with opioid use. Her care plan directed staff to administer pain medications as ordered. The MAR showed gabapentin doses given several hours late on multiple occasions, including morning and evening doses outside the scheduled time. R122 stated her pain medications were often not administered on schedule, particularly when certain nurses were working, and that delayed doses caused her pain to worsen. R127 was admitted with diagnoses including long-term opiate use, abdominal pain, joint pain, and right shoulder pain. Her MDS showed moderate cognitive impairment. Her care plan focused on comfort and directed staff to administer pain medications as ordered. The MAR showed Norco doses given outside the acceptable administration times on multiple occasions, including doses late in the morning and evening and one dose given after midnight. R127 stated she received routine pain medication but that it was late on at least one occasion. Staff interviews identified call-offs, staffing interruptions, and late assignment to the medication cart as reasons medications were administered late. The Medical Director, DON, and Administrator all stated medications were expected to be given according to physician orders and facility policy.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were properly stored, labeled, secured, and maintained in accordance with accepted standards of practice in 2 of 3 medication rooms. On 01/14/2026, observation of the Unit A Medication Room with the DON revealed numerous medications from other facilities that residents had brought with them on admission were stored together with clean supplies and overstock medications. The same observation also found an opened bottle of TB serum that was not dated or labeled to show when it had been opened. A similar observation of the Unit B Medication Room with the DON on 01/14/2026 found numerous medications from other facilities brought in by residents on admission commingled with clean supplies and overstock medications. The observation also revealed an opened insulin pen that was not dated when opened and did not have a pharmacy label identifying the resident's name or providing pharmacy directions. During interview, Pharmacy Client Services staff stated there was an abundance of medications from other facilities still on-site. The DON stated the facility did not maintain records of discontinued medications unless they were controlled medications, and she expected staff to date medications when opened and ensure all medications had pharmacy labels. The Administrator stated she expected nursing staff to follow the facility's medication policies for safe medication administration and storage.
Failure to Support Resident Clothing Preferences and Dignity
Penalty
Summary
The facility failed to ensure that residents were supported in exercising their right to self-determination, including choices related to personal care, for 2 of 31 sampled residents, R53 and R1. Facility policies stated residents should be treated with respect and dignity, assisted in fully exercising their rights, and supported with clothing and personal space in a manner that promoted quality of life and protected dignity. For R53, the resident was admitted with diagnoses including degenerative disease of the nervous system, need for assistance with personal care, and muscle weakness, and had a BIMS score of 13/15, indicating cognitive intactness. The resident’s care plan identified a need for supervision with lower body dressing and total staff assistance with footwear. Observations on multiple days showed R53 seated in a wheelchair wearing only a shirt and adult incontinence brief, without pants; on one occasion a sheet was draped over the legs instead. R53 stated he wanted pants, had asked multiple staff throughout the day, and felt embarrassed, reporting he went without pants daily. Staff interviews confirmed they did not offer alternative clothing or ask his preference after incontinent episodes, and the DON and Administrator stated he should have been appropriately covered and provided pants. For R1, the report identifies the resident’s admission diagnoses and intact cognition, but the narrative provided is cut off before the specific care plan details and observed events are fully described.
Resident Left in Stained Clothing and Room Not Kept Clean
Penalty
Summary
The facility failed to provide a resident environment that was consistently clean, comfortable, and home-like for one resident. The resident was admitted with COPD, schizoaffective disorder bipolar type, and depression, and the admission MDS indicated a BIMS score of 14 out of 15, showing the resident was cognitively intact. The resident’s care plan did not identify refusal of care as a concern or include it as a planned behavior, and facility policies stated residents should be treated with respect, dignity, and in an environment that promoted quality of life. Observations showed the resident wearing the same shirt and pants stained with what appeared to be coffee or coke and food on multiple days. The resident’s room also had spilled food on the floor, including cheerios, a plate with unknown food items, and an opened graham cracker container scattered on the floor, while the breakfast tray remained covered and untouched on the bedside table. The resident’s family member stated concerns had been raised to staff and that a nurse responded, “I’m agency,” and also stated hospice was helping with bathing and activities of daily living. Staff interviewed stated residents were expected to be dressed in clean clothing daily, and both the DON and Administrator stated they expected residents’ clothing to be changed daily.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to notify the resident and the resident’s representative in writing, in a language and manner they understood, of the bed hold notice and the transfer or discharge and the reasons for the move for 2 of 7 residents reviewed for transfer and/or discharge, R8 and R24. The facility’s policy stated that transfer/discharge notices would be provided to the resident and resident’s representative in a language and manner they could understand. R8 was admitted with diagnoses including diabetes, cognitive communication deficit, and dementia, and later had a BIMS score of 15 out of 15, indicating cognitive intactness. After R8’s emergency transfer to the hospital, the notice documented that paperwork for the representative was sent with the resident, but the Activity Report documented the BOM hand carried the bed hold notice to the resident and did not document written notification to the representative regarding the bed hold or the reason for the transfer or discharge. R24 was admitted with diagnoses including metabolic encephalopathy, acute kidney failure, and chronic kidney disease stage four, and later had a BIMS score of 15 out of 15. The resident had multiple hospital transfers, and several Bed Hold Notices documented the reason for transfer, but the facility did not provide written notification to the resident’s representative regarding the notice, the transfer or discharge, or the reasons for the move. The SSA surveyor was unable to contact the representative by telephone. During interviews, the BOM stated bed hold notices were done face to face or sent by certified mail when the resident was not their own person, but also stated she did not notify representatives in writing if the resident was their own person. The DON stated nursing did not do bed hold notification and reason for transfer notifications, and the Administrator stated it was her expectation that these notices be sent to the resident or representative and documented at least once.
Failure to Follow Tube Feeding Care Plan and Physician Orders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan to address the medical needs of one sampled resident with dysphagia, moderate protein-calorie malnutrition, and hemiplegia. The resident’s quarterly MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and that 51 percent of total calories were received through parenteral or tube feeding. The resident had a physician order for enteral feeding of Two-Cal HN at 50 mL/hr continuous, and the comprehensive care plan addressed tube feeding related to dysphagia, poor oral intake, and refusal of meals with an intervention to follow physician orders for current feeding orders. During observations on two separate days, the resident was receiving enteral nutrition via g-tube at 65 mL/hr, while the feeding container was labeled for 50 mL/hour and documented as hung the prior day; the time and initials of the nurse were illegible. Staff interviews stated that nurses were expected to follow the physician’s orders and the care plan as written, and the DON, Administrator, MDS/IP nurse, RD, and Medical Director all stated that staff were expected to follow the resident’s care plan and physician’s orders for tube feeding and nutrition. The Medical Director stated that over-infusion of enteral feeding could cause aspiration risk, nausea, vomiting, and/or diarrhea.
Improper Transfer Lift Use Led to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was free from accidents and received adequate supervision and the correct assistive device during transfers. The resident was admitted with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, cerebral infarction, dependence on a wheelchair, and difficulty walking. The quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and the resident was totally dependent on staff for chair and bed transfers. The care plan, PT note, physician orders, and STNA Kardex all identified that a Hoyer lift was to be used for all transfers. The facility's Fall Investigation documented that staff attempted to transfer the resident from a wheelchair to a bed using a sit-to-stand mechanical lift, and the resident slid out of the chair onto the floor while standing. Family stated the resident fell because staff used the wrong mechanical lift and that the sit-to-stand lift was used for the transfer. An STNA stated staff primarily used the sit-to-stand lift and only used the Hoyer lift when the resident was fatigued and unable to stand on his own because he preferred the sit-to-stand lift. The DON stated staff were expected to use the Hoyer lift for all transfers, and the Administrator stated she expected staff to follow facility policy and physician orders for transfers.
Incorrect Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to prevent complications of enteral feeding for one sampled resident with a feeding tube. The resident was admitted with diagnoses including dysphagia, moderate protein-calorie malnutrition, and hemiplegia, and the quarterly MDS showed severe cognitive impairment with a BIMS score of 0 out of 15. The resident was dependent for ADLs and required substantial to maximal assistance for mobility in bed. The resident had physician orders for continuous Two-Cal HN enteral feeding at 50 mL/hr and free water flushes of 250 mL five times daily via tube feeding. The care plan addressed tube feeding related to dysphagia, poor oral intake, and refusal of meals, with a goal that the resident remain free of complications related to tube feeding. However, observations on two separate days showed the enteral feeding pump infusing at 65 mL/hr while the feeding container was labeled for 50 mL/hr and documented as hung the prior day, with the time and initials illegible. During interview, an LPN stated she had not yet checked the pump, had not seen the resident, and did not realize the pump had been programmed above the ordered rate. She also stated the facility did not conduct beginning-of-shift rounding or bedside shift report at the start of the shift where concerns could be identified. The RD, DON, Administrator, and Medical Director each stated staff were expected to follow physician orders and verify the pump was set correctly, and the Medical Director stated overinfusion could cause aspiration risk, nausea, vomiting, and/or diarrhea.
Incomplete Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure residents who required dialysis services received those services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences for 2 of 2 sampled residents, R10 and R24. The facility’s policy titled Dialysis Care stated that facilities shall use a form to communicate between the dialysis center with each visit. R10 was admitted with CHF, dementia, CKD stage three, and diabetes mellitus, had a BIMS score of 3 out of 15 indicating severe cognitive impairment, and was care planned for hemodialysis Monday, Wednesday, and Friday for ESRD. Although R10 had dialysis orders and a Dialysis Center Communication Record in the chart, the record contained three incomplete forms and no completed forms were found since admission. During interview, R10 was unable to state his name and initially stated he did not receive dialysis before being corrected by his roommate. R24 was admitted with metabolic encephalopathy, acute kidney failure, and CKD stage four, and was later diagnosed with ESRD and dependence on renal dialysis. R24 had orders for hemodialysis three days per week and was care planned for dialysis, but the Dialysis Center Communication Record reviewed for multiple dialysis dates was largely incomplete, with four of five forms incomplete and prior dialysis date forms not received. The dialysis center Administrator stated the facility was supposed to receive a dialysis communication form but very rarely did, and the DON and LPN described that forms were often not returned and had to be requested. The DON also stated medical records did not have any HD communication forms, and the Administrator stated it was extremely important to communicate back and forth with dialysis.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests and rodents, as required by its policy. The facility’s Resident Environmental Quality policy stated it must maintain an effective pest control program so the facility is free of pests and rodents. The pest control agreement covered specified pests, including general pests, ants, crickets, mice, millipedes/centipedes, spiders, pill/sowbugs, and German roaches, but the record review showed no documented reports or issues related to gnats in the maintenance logbook or pest control invoices. The contracted pest control company stated it treated common areas and up to five resident rooms, and that gnat treatment alone would not fully resolve the issue because gnats are linked to sanitation issues; the company also stated the facility had not made it aware of any gnat concerns. Resident 2 was admitted with COPD, schizoaffective disorder bipolar type, and anxiety, and had a BIMS score of 14, indicating cognitive intactness. Observations on multiple days showed gnats on the resident and in the resident’s room, including gnats present in the room, on the resident, and around cleaned nebulizer parts placed on a napkin next to the sink. The resident could not be interviewed because the surveyor found the resident with eyes closed and appearing asleep. Family reported concerns about gnats, and staff interviews reflected that gnats in a resident’s room would not meet the expectation of a clean, home-like environment and should be reported to housekeeping or maintenance. Resident 53 was admitted with chronic diastolic heart failure, dementia, and degenerative disease of the nervous system, and had a BIMS score of 13, indicating cognitive intactness and ability to express concerns. During observation, the resident was seated in a wheelchair eating lunch while multiple gnats flew around and landed on the resident’s food tray. The resident stated bugs landing on the food was gross and asked for different food. Staff interviews confirmed that gnats in a resident’s room did not meet the expectation of a home-like environment and should be reported for treatment. The DON and Administrator both stated gnats should be addressed immediately, and the Administrator stated she was unaware of any gnats until that week, though she reported a prior gnat issue in the same room about six months earlier.
Failure to Safeguard Controlled Substances Results in Unmanaged Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for residents requiring such services by not safeguarding and accounting for controlled substances, which led to the diversion of narcotic medications by a staff member. This resulted in ordered pain medications not being available for administration, causing unmanaged pain and discomfort for three residents. A comparison of medication counts and controlled substance record sheets revealed discrepancies, and an investigation found that scheduled narcotic pain medications were not administered as ordered. One resident with chronic pain syndrome, osteomyelitis, and peripheral vascular disease reported almost constant pain with high intensity and did not receive scheduled doses of oxycodone. The resident stated he was in severe pain for two days due to missed doses. Another resident with liver cancer and chronic pain, who was also receiving hospice services, missed a dose of morphine and reported severe pain, stating he cried because the pain was so bad. A third resident with pain, major depressive disorder, and personality disorder missed a dose of oxycodone-acetaminophen and reported increased pain, with staff unable to provide the medication due to its unavailability. Documentation in the medical records was incomplete, with no pain assessments or evidence that staff assessed or addressed the residents' pain or notified providers about missed medications. Interviews with staff confirmed that residents' complaints of pain were not properly documented or communicated to providers, and the controlled substance counts were inaccurate. The facility's failure to follow its own policies for controlled substance management and pain assessment led to residents experiencing unmanaged pain due to missed doses of prescribed narcotic medications.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice and its own policy. Licensed nurses were required to count all controlled medications at every change of shift, with reconciliation performed jointly by outgoing and incoming nurses, and documentation required at the time of administration. However, observations and record reviews revealed that an LPN did not accurately complete and reconcile controlled medication record sheets for four sampled residents. The LPN administered controlled medications but failed to document the administration on the Individual Patient Controlled Substance Administration Record (IPCSAR) at the time the medications were given. Instead, the LPN completed the documentation later, in front of a surveyor, and recorded the time as after the actual administration. The residents involved had various medical conditions, including cerebral infarction, paranoid schizophrenia, contractures, Parkinson's disease, osteoarthritis, anxiety disorder, chronic pain, COPD, and dementia. Each resident had physician orders for controlled medications such as gabapentin, pregabalin, morphine sulfate, oxycodone, and lorazepam. Medication Administration Reports (MARs) indicated that the medications were given as scheduled, but the corresponding controlled substance records were not signed at the time of administration. In some cases, the LPN provided explanations for the lack of timely documentation, such as not having a pen, and stated an intention to complete the records after finishing medication administration. Interviews with other nursing staff and the Director of Nursing confirmed that the facility's policy required controlled medications to be signed out at the time of administration and that staff had been educated on this process. The Director of Nursing acknowledged ongoing issues with nursing documentation and stated that all staff, including agency nurses, were expected to follow established procedures for controlled medication counts and documentation. The administrator also confirmed the expectation that nurses follow all facility policies for controlled substances, including logging and documentation at the time medications are given.
QAPI Oversight Failed to Sustain Narcotic Documentation and Pain Medication Monitoring
Penalty
Summary
The facility failed to implement and sustain its Plan of Correction related to monitoring narcotic sign-out sheets and timely administration of pain medications. Review of the facility’s QAPI policy showed the program was intended to use data-driven processes, root cause analysis, and leadership oversight to improve resident care. The facility’s PoC required the DON to monitor controlled substance administration records from medication carts and to audit pain assessments, with results to be referred to the QA/QAPI Committee for further action. The QA/QAPI Committee included the Medical Director, DON, Administrator, Infection Preventionist, Social Service Director, and MDS Coordinator. During observation of the A Hall medication cart, an LPN did not sign out a resident’s 8:00 AM gabapentin dose when it was removed from the bubble pack. The LPN later returned to the cart and stated the medication had already been administered and that she was only then completing the required sign-out documentation. Review of the IPCSARs for the A, B, and C Hall medication carts showed a repeated pattern of nursing staff failing to accurately document controlled substance removal and administration, with narcotic sign-out times often reflecting the ordered time rather than the actual administration time documented on the MAR. Across the survey, controlled narcotic record sheets were not completed at the time of removal for 11 of 11 sampled residents. Review of the records for four residents who were care planned for pain medication showed multiple instances in the prior three weeks where pain medications were administered late, sometimes more than three hours past the scheduled time and outside the facility’s medication window. Interviews with those residents indicated the delays caused worsening pain. The DON stated her audits were limited to live observations and did not compare IPCSAR entries with the MAR or include random audits across all shifts, and she said prior auditing was too limited to identify discrepancies. The Administrator and Medical Director both confirmed that the QAPI committee discussed narcotic administration, documentation, and pain management concerns, and the Medical Director stated late administration could affect pain relief and contribute to anxiety and behaviors.
Incomplete Refrigeration Temperature Logs
Penalty
Summary
The facility failed to store food safely as evidenced by incomplete refrigeration storage logs. During an observation on 10/14/2024, it was noted that the Monthly Temperature Log for refrigeration equipment was missing entries for eight out of 14 days in October 2024. The log is intended to record daily temperatures for the refrigerator, freezer, and dry storage to ensure they are within the specified ranges: Fridge 32-41°F, Freezer below 0°F, and Dry Storage 50-70°F. The absence of recorded temperatures for several days indicates a lapse in monitoring the equipment's functionality. Interviews with facility staff, including the Dietary Supervisor and Dietary Director, revealed that the failure to document temperatures was due to the Dietary Supervisor covering multiple shifts and forgetting to record the data. Both acknowledged the importance of maintaining proper temperatures to prevent bacterial growth and ensure food quality. The Assistant Director of Nursing and the Administrator also recognized the potential for food spoilage if refrigeration equipment is not functioning correctly, emphasizing the expectation for regular temperature checks and documentation.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs used were labeled according to professional standards and used before their expiration dates. During an observation, a medication cart on C1 Hall was found to contain a multi-dose vial of Novolog insulin that had been opened on September 10, 2024, and exceeded the 28-day use date by eight days. Additionally, the cart contained medications such as Pro-Air multi-use inhaler, guaifenesin syrup, and milk of magnesia, which were opened but not dated. Another observation on C2 Hall revealed an unopened epinephrine pen that had expired in July 2024. Interviews with nursing staff and a pharmacist highlighted the responsibility of nurses to ensure medications are not expired and are labeled with the date opened. The staff acknowledged the risk of decreased effectiveness of expired medications. The Assistant Director of Nursing and the Administrator emphasized the expectation for nursing staff to adhere to the facility's policies, which include monitoring medication carts for expired drugs and ensuring proper labeling.
Deficiency in Serving Hot Food at Proper Temperature
Penalty
Summary
The facility failed to serve hot food at a proper and palatable temperature, as observed during a test tray evaluation. On 10/16/2024, scrambled eggs served to residents were found to be at 114 degrees Fahrenheit, which is below the expected temperature for hot foods. The facility's policy requires hot foods to be served as hot as safely possible to meet the palatability requirement of the resident community. However, the scrambled eggs were not served at the appropriate temperature, leading to dissatisfaction among residents. The Dietary Meal Temperature Log indicated that the scrambled eggs were initially at 172 degrees Fahrenheit at 7:30 AM and 170 degrees Fahrenheit at 8:15 AM, suggesting a failure in maintaining the temperature until the point of service. Interviews with staff revealed issues with the warming process. The Dietary Manager and Supervisor acknowledged that plates were not adequately heated, and the scrambled eggs were not hot enough to be acceptable to residents. A resident expressed dissatisfaction with the cold food and reported that staff became frustrated when asked to warm the food. The Assistant Director of Nursing expected food to be served at the proper standard temperature, and the Administrator stated that if hot food was cold, a new tray would be provided. These observations and interviews highlight a deficiency in the facility's food service process, impacting the quality of meals served to residents.
Infection Control Deficiencies in Medication Administration and Tray Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in increased risk for healthcare-associated infections for two residents. During medication administration, an LPN did not perform hand hygiene or use gloves when administering medications, including eye drops, to a resident. Additionally, the LPN had an open bottle of iced coffee on the medication cart, which is against infection control practices. An Activity Assistant also failed to wash hands or use gloves while assisting a resident with their breakfast, directly handling the food with bare hands. Interviews with the LPN and Activity Assistant confirmed their awareness of the proper procedures, which they neglected to follow. Furthermore, the facility did not manage used meal trays properly in the C Unit/COVID Unit kitchenette. Observations revealed that soiled breakfast and lunch trays were left on the sink, potentially leading to cross-contamination. Staff interviews indicated that the trays were left due to the unavailability of a tray cart for late trays, and dietary staff were responsible for picking them up. Despite staff assertions that there was no cross-contamination risk, the improper handling of soiled trays in a non-food prep area was noted as a concern.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 785 citations issued within 25 miles in the last 12 months — including the 5 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belmont Terrace Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Villaspring Of Erlanger | 1.3 mi | ★★★★★ | 5 | 0 |
| Village Care Center | 2.6 mi | ★★★★★ | 7 | 0 |
| Emerald Trace | 2.7 mi | ★★★★★ | 6 | 0 |
| Woodcrest Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.