Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
8E
6F
Potential for minimal harm
0A
0B
0C
April 8, 2026Complaint inspection · 1 citation
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on observations, record review and interviews, the facility failed to coordinate an outside medical appointment for one resident (#1) out of three residents reviewed for medical appointments.
August 27, 2025Standard inspection · 19 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, interviews and record review the facility failed to ensure sufficient kitchen staff for four out of eight days reviewed. Findings Included:During an observation on 08/24/2025 at 9:23 a.m., three staff members Staff P, Cook, Staff Q, Certified Nursing Assistant (CNA) and Staff R, Dietary Aide were observed in the kitchen area. Review of the punch detail report for dietary staff for 07/24/2025 thru 08/25/2025 revealed:08/24/2025 one cook and one dietary aide clocked in for the morning shift.08/22/2025 one cook and one dietary aide clocked in for the afternoon shift.08/18/2025 one cook and one dietary aide clocked in for the afternoon shift.08/17/2025 one cook and one dietary aide clocked in for the afternoon shift. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interviews and record review the facility failed to provide a clean and sanitary environment in the kitchen related to undated, unlabeled food items, properly disposing of food items, and following hand hygiene practices for staff. Findings Included: On 8/24/2025 at 9:21 a.m., an initial tour of the facility’s kitchen revealed Staff P, Cook, preparing breakfast plates, and Staff Q, Certified Nursing Assistant (CNA) plating trays. Food trays on a meal cart were observed with Styrofoam containers. A three compartment sink behind the cook side of the meal service line was observed with dirty pots and pans. On the sink was a bag of boiled eggs and bags of pancakes. Clean plate covers next to an open trashcan near the dish washing area. [...]
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interviews the facility failed to update the facility-wide assessment to determine emergency plans, staff competencies needed for care of residents with different types of acuities and specific staffing needs for each shift. Findings Included: Review of the facility assessment dated [DATE] revealed there was not a section for emergency plans, staff competencies needed for care of residents with different types of acuities and specific staffing needs for each shift. During an interview on 08/27/2025 at 12:30 p.m., the Staffing Coordinator stated she staffs the facility daily to meet the needs of the residents based off of the daily census. She was unsure what the facility assessment was. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective Infection Control program related to ensuring meal carts were closed when unattended not offering residents hand hygiene prior to meals on one (100-high) of 4 hallways and two dining rooms observed, failed to remove red-stained towel from under one (#114) of one dialysis resident, failed to ensure sharps container was managed in a manner promoting safety, and failed to ensure one of one laundry room was clean.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record reviews and interviews, the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use. On review, the monitoring was not completed for four months. A review of the Antibiotic Stewardship Book on 8/27/25 at 1:40 P.M. revealed the antibiotic surveillance for August 2025 was missing. A review of May, June, and July 2025 revealed the surveillance forms are incomplete. The forms did not have the required information based on policy. The forms contained spaces for required documentation to be completed. The book did not contain mapping of infections throughout the building for months May 2025 through August 2025. An interview with the Director of Nursing (DON) on 8/27/25 at 2:25 P.M. was conducted. She said she is the facility's dedicated Infection Preventionist. She said the Antibiotic Stewardship Policy is reviewed annually. [...]
- E
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.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a building in good repair, related to cleanliness, holes in walls, bio growth and unpainted walls in two wings (100 East, 200 East) of the four facility wings toured.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide activities on three out of four days observed.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were offered the Influenza vaccine annually and offered the Pneumococcal Vaccine for four (Resident #3, #88, #110, and #119) of five residents sampled. Review of Resident #3, #88, and #119 records showed the resident was not offered the Influenza Vaccine. Review of Resident #110 records showed the resident was offered the Influenza Vaccine and no documentation that indicated the resident received the Influenza Vaccine. Review of Resident #88 and #119 records showed the resident was not offered the Pneumococcal Vaccine. Review of Resident #3 records showed the resident was offered the Pneumococcal Vaccine and no documentation that indicated the resident received the Pneumococcal Vaccine. An interview with the Director of Nursing (DON) on 8/27/2025 at 2:25 P.M. was conducted. [...]
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, the facility failed to ensure residents were offered the COVID Vaccine for three (Resident #3, #88, and #119) of five residents sampled. Review of Resident #3 records showed the resident was not offered the COVID Vaccine. Review of Resident #88 and #119 records showed the resident was offered the COVID Vaccine and no documentation that indicated the resident received the COVID Vaccine. An interview with the Director of Nursing (DON) on 8/27/2025 at 2:25 P.M. was conducted. She said she is the facility's dedicated Infection Preventionist. She said she is waiting on a new code from Florida Shots. She said she hasn't checked any of the residents' immunization status. She said her expectation is the residents are offered Influenza, Pneumonia, and COVID vaccine every 5 years. [...]
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the grievance process was followed for one resident (#45) and Resident Council members out of three residents reviewed for grievances.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to complete a Level II Pre-admission Screening and Resident Review (PASRR) for one resident (#3) and failed to ensure the accuracy of a Level I PASRR for one resident (#4) out of thirty-five initial pool residents. On 8/24/25 at 12:25 p.m. Resident #3 was observed lying in bed, with eyes closed and rhythmically breathing. Review of Resident #3’s admission Record showed the resident had been admitted on [DATE]. The record included diagnoses not limited to unspecified bipolar disorder, unspecified insomnia, and unspecified depression. Review of Resident #3’s PASRR dated 7/11/25 revealed it was completed at this facility and showed the resident had diagnoses of bipolar disorder, depressive disorder, and Post-Traumatic Stress Disorder (PTSD). [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide nail care for two residents (#97 and #45) out of five residents sampled for activities of daily living.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance out of the bed for one dependent resident (#127) out of four residents sampled. On 08/24/2025 at 10:00 a.m., Resident #127 was observed lying down in bed with her call light within reach. She said staff will not assist her on the toilet whenever she asked them. On 08/24/2025 at 1:00 p.m., and on 08/24/2025 at 11:00 a.m., Resident #127 was observed lying down in bed. She said she has not been able to go to activities because staff will not get her up. Review of Resident #127's admission Record revealed Resident #127 was admitted to the facility on [DATE] with diagnoses to include but not limited to muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified fracture of right femur, sequela, type 2 diabetes mellitus with unspecified complications. [...]
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to assess and obtain podiatry services for one (#114) of one resident sampled for foot care and podiatry needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to initiate care plan interventions related to the placement and functioning of an electronic wander device for one (#97) of one resident sampled and to ensure staff followed protocol when a door alarm system alerted of an issue.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record reviews and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as body weight for two (Resident #3 and #28) of three residents sampled. Review of Resident #28s admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to Muscle Wasting and Atrophy not elsewhere classified multiple sites, Iron Deficiency Anemia, Oropharyngeal Phase Dysphagia, Type 2 Diabetes Mellitus, and Depression. Review of Resident #28s weight summary showed on 4/3/25 the resident weighed 233.6# via mechanical lift, on 5/14/25 the resident weighed 224# via mechanical lift, a weight loss of 9.6#s and weight loss of 4.11%, and on 8/12/25 the resident weighed 198.2# via mechanical lift, a total weight loss of 35.4# and a total weight loss of 15.15% since admission. [...]
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the intravenous catheter dressing for one (#97) of one resident sampled for catheter dressing was changed per professional standards and per facility expectation.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review and interviews the facility failed to post the Daily Nursing Staffing form appropriately. Findings Included: During an observation on 08/24/2025 at 9:00 a.m., the Daily Nursing Staffing form was located on the wall near the reception area. The date on the form was 08/21/2025. (Photographic Evidence Obtained)During multiple observations from 08/24/2025 thru 08/27/2025 revealed the Daily Nursing Staffing form was not posted on the 2nd floor. During an interview on 08/27/2025 at 12:30 p.m., Staffing Coordinator stated the daily nursing staffing form is only posted at the entrance. The supervisor is responsible for updating and posting the form on the weekends. During an Interview on 08/27/2025 at 2:06 p.m., the Nursing Home Administrator (NHA) stated the daily nursing staffing form is only posted up front. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the medication error rate was less that 5.00%. Thirty medication administration opportunities were observed and two errors were identified for one (#17) of five residents observed. These errors constituted a 6.67% medication error rate.
April 16, 2025Complaint inspection · 3 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#2) of three residents dependent upon staff to feed at meal times, was provided supervision and services related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on 3/27/2025 at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance. [...]
- J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to implement care plan interventions to provide supervision and assistance during meals for one resident (#2) of three residents dependent upon staff to feed at meal times, related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on 3/27/2025 at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance in accordance with the plan of care. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#2) of three residents dependent upon staff to feed at meal times, was provided supervision and services related to the resident's difficulty swallowing and history of cerebral infarction and dementia. The facility staff failed to ensure the safety of Resident #2; on 3/27/2025 at approximately 5:15 p.m., Resident #2 was provided a covered food tray in the resident's room by facility staff. Resident #2 consumed a portion of her dinner meal unsupervised and without assistance. [...]
February 6, 2024Complaint inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain a clean and sanitary kitchen as evidenced by dust attached to the wall above the coffee pot and plate covers, the outside of the oven appeared to have dried grease collected on it, and inside the one of one ice machine contained black biogrowth.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services related to wound care including following standard infection control practices for 4 (#5, #6, #7, #24) of 4 sampled residents.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review, the facility failed to arrange and provide transportation to medical appointments for 2 out of 4 sampled residents (#11 and #14).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the medical record of two (#1 and #10) of 4 residents was complete and contained accurately documented incidents requiring a transfer to an higher level of care.
July 19, 2023Standard inspection · 3 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure food items in the walk-in refrigerator were labeled, dated, and discarded when expired. The failed practice had the potential to effect 108 of 110 residents who received food from the facility's kitchen.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure resident dignity for residents who require assistance while eating their meals for two (Residents #45 and #307)) of 48 sampled residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, staff interview, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), the facility failed to complete the Preadmission Screening and Resident Review Level II upon a new qualifying mental health diagnosis for five (Resident #10, #40, #80, #78, and #30) of thirty-two residents sampled for PASARR Level II.
August 6, 2021Standard inspection · 7 citations
- E
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.
Inspectors wroteBased on observations, staff interviews and facility record review, the facility failed to ensure resident areas and shower equipment were clean, maintained and sanitized during four of four days observed (8/3/2021, 8/4/2021, 8/5/2021, and 8/6/2021), in three community shower rooms (1st floor 100 Unit, two on 2nd floor 200 Unit) of four community shower rooms, one dining room (main) of two dining rooms, and one smoking porch of one smoking porch. It was determined that 1. a constant water drip from the ceiling was pooling and flowing down the main hallway (100 Unit); 2. shower room chairs, walls, and water nozzles were observed with black biogrowth (where); 3. the main dining room was observed with ceiling vents caked with black and gray dust/debris; and 4. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews the facility failed to maintain the kitchen and kitchen equipment were maintained in a clean and sanitary manner during two of two days observed (8/3/21 & 8/6/21) related to heavy black biogrowth and dust debris observed on two of two large air return vents and a motor housing with plastic venting, positioned directly above food items in one of one walk in refrigerators.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, staff interviews and medical record review, the facility failed to ensure one resident (#161) was not able to self-administer medications by one staff member (C ) leaving the resident without ensuring the resident took the nine medications, and without returning during a medication pass out of a total of thirty-eight sampled residents.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one resident (#47) out of 9 sampled vulnerable residents was free from a physical restraint which could not be self-released. There was no medical symptom identified as the basis of the need for the restraint, and the facility failed to ensure that monitoring and evaluation for the continued use of the physical restraint was ongoing.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, medical record review and staff interviews, the facility failed to implement care plan interventions related to monitoring and providing assistance for eating for one resident (#160) of thirty-eight sampled residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide needed treatment and services related to a leakage of a suprapubic tube for one resident (#64) out of 9 residents receiving catheter care.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews and record review, the facility did not ensure that suction canisters were changed consistent with the physician order for two residents (#64 and #101) out of four sample residents reviewed for tracheostomy care/tracheal suction.
Fire safety inspections
22 fire safety citations on file: 7 on August 27, 2025, 10 on July 19, 2023, 5 on August 6, 2021.
Every fire safety citation22 citations
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Develop Emergency Preparedness policies and procedures.
E 13 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Develop a communication plan.
E 29 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 27, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 27, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 19, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · July 19, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · July 19, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · July 19, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 19, 2023 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 19, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 19, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 19, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 19, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 19, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 6, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 6, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 6, 2021 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 6, 2021 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 6, 2021 · Corrected (the home has a date of correction)