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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
5E
0F
Potential for minimal harm
0A
0B
0C
May 23, 2025Standard inspection, Complaint inspection · 8 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 3 (#47, 54, and #161) of 15 sampled residents reviewed for baseline care plans. The administrator identified 55 residents resided in the facility.
- E
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to ensure the direct care staffing hours on the Quality of Care report were accurately reported. The administrator identified 55 residents resided in the facility.
- D
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.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's DNR was valid for 1 (#212) of 15 sampled residents reviewed for advance directives. The administrator identified 55 residents resided in the facility.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for 1(#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dented cans, and opened bottles were removed from circulation in the dry storage. The administrator identified 55 residents resided in the facility and ate from the kitchen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to ensure a water management plan to prevent waterborne pathogens had been implemented. The administrator reported 55 residents resided at the facility.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview, the facility failed to ensure abuse training on hire was conducted for 1 (CNA #2) of 3 staff members files who's employee files reviewed. The administrator identified 55 residents resided in the facility.
February 23, 2024Standard inspection · 9 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Administrator identified 49 residents resided in the facility.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised for three (#34, 40, and #32) of 13 sampled residents reviewed for care plans. The Administrator identified 49 residents resided in the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure: a. fall interventions were care planned after falls and have a process for notifying staff of interventions for one (#34), b. fall interventions were implemented and care planned after falls for one (#40), and c. a fall assessment was completed for one (#32) of three sampled residents reviewed for falls. The Administrator identified 49 residents resided in the facility.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff investigated reports of misappropriation of resident items for one (#1) of one sampled resident for misappropriation of property. The Administrator identified 49 residents resided in the facility.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#40) of one sampled resident reviewed for PASRR. The Administrator reported 49 residents resided in the facility.
- 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 record review and interview, the facility failed to ensure a comprehensive care plan was developed for psychotic disorder with delusions for one (#40) of 13 sampled residents whose care plans were reviewed. The Administrator reported 49 residents resided in the facility.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed for one (#51) of two sampled residents reviewed for discharge. The Administrator identified 49 residents resided in the facility.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's specialist appointment was completed timely for one (#34) of one sampled resident reviewed for social services. The Administrator identified 49 residents resided in the facility.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were offered for one (#104) of five sampled residents reviewed for immunizations. The Administrator identified 49 residents resided in the facility.
February 20, 2024Complaint inspection · 1 citation
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure two trash dumpster's were covered. The Daily Census, dated 02/09/24, documented 52 residents resided in the facility.
January 26, 2023Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 2 on May 23, 2025, 1 on February 23, 2024, 3 on January 26, 2023.
Every fire safety citation6 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 26, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 26, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 26, 2023 · Corrected (the home has a date of correction)