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| Deficiency Category | Inspection Date: 8/1/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 2/23/24 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 8/6/23 Complaint Reporting Period: 3/1/22 - 2/28/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 8/1/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | No complaint inspections |
| Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Florida: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 8/1/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/1/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Infection Control Deficiencies were found during this inspection period. |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 8/1/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 2/23/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Florida: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 2/23/24 | 3/23/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 2/23/24 | 3/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Plan the resident's discharge to meet the resident's goals and needs. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 2/23/24 | 3/23/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Some |
| Date of last standard health inspection: | 8/6/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 1/26/23Read the full report (PDF) 12/8/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 5/27/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Florida: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Assist a resident in gaining access to vision and hearing services. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide or obtain dental services for each resident. | 8/6/23 | 11/27/23 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 12/8/22 | 1/8/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/26/23 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure staff are vaccinated for COVID-19 | 5/27/22 | 6/9/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Observe each nurse aide's job performance and give regular training. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 12/8/22 | 1/8/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 12/8/22 | 1/8/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 12/8/22 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 8/6/23 | 11/27/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | 12/8/22 | 1/8/23 | 2 - Minimal harm or potential for actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 1/26/23 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Plan the resident's discharge to meet the resident's goals and needs. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | 5/2/23 | 5/21/23 | 2 - Minimal harm or potential for actual harm | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 12/8/22 | 1/8/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/26/23 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 12/8/22 | 1/8/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 8/6/23 | 11/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 12/8/22 | 1/8/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 1/26/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 12/8/22 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | 12/8/22 | 1/8/23 | 2 - Minimal harm or potential for actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 1/26/23 | 5/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure staff are vaccinated for COVID-19 | 5/27/22 | 6/9/22 | 2 - Minimal harm or potential for actual harm | Some |