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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
4E
0F
Potential for minimal harm
0A
0B
0C
October 29, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and a safe environment to prevent an elopement for 1 of 4 sampled residents (Resident #1). Resident #1 was a vulnerable resident who exited the facility's main front door unsupervised on 10/11/25. She was found about half mile away from the facility on a very busy 6-lane roadway at 7:32 PM by the police who were driving down the road by chance and noticed she needed assistance. The police took the resident to the facility, and the facility staff were unaware Resident #1 had left. The facility's failure to prevent Resident #1 from eloping placed this resident at a likelihood of serious harm, injury or death. While out of the facility on 10/11/25, Resident #1 was confused and unable to report to the police officer where she lived. [...]
August 27, 2025Standard inspection · 7 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their menu for the Regular diet for 1 of 1 visit to the main kitchen. This has the potential to affect 70 residents on regular diet. The census at the time of survey was 113.
- 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 and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to ensure the prevention of foodborne illnesses for 2 of 2 visits to the central kitchen; and failed to discard expired products, to appropriately separate dented cans, and to date and properly cover food in the walk-in refrigerator.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor residents' dignity for 1 out of 1 resident reviewed for assistance during dining. (Resident # 10).
- 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, interviews, and record reviews, the facility failed to initiate a nursing care plan for an external urinary catheter system device for 1 of 4 sampled residents, reviewed for urinary care, Resident 94.
- D
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 observations, interviews and record review, the facility failed to revise and update care plans in timely manner for 2 of 23 sampled residents, Residents #7 and #96.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, for 2 of 23 sampled residents observed during dining, Resident #91 and Resident #107.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP), for residents with urinary catheter drainage systems for 2 of 36 sampled residents for EBP, and 2 of 4 sampled residents for urinary care (Resident # 94 and Resident #69); failed to care and manage a urinary catheter system according to the nursing care plan for 1 of 36 sampled residents for EBP, and 1 of 4 sampled residents for urinary care (Resident #36); failed to care and manage a resident with post-surgical incision for 1 of 36 residents for EBP (Resident # 123); and failed to manage the care of a resident with an intravenous (IV) access line for 1 of 36 sampled residents for EBP (Resident #57).
August 22, 2024Complaint inspection · 2 citations
- E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interviews and record review, the facility failed to ensure residents funds account were disbursed in 30 days to the representative after the residents' death for 3 of 3 sampled residents, Resident #1, #2 and #3.
- 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 interviews and record review, the facility failed to making prompt efforts to resolve a resident's Power of Attorney (POA) grievance sent on [DATE], as evidenced by the lack of written documentation of follow-up communication with the representative until the representative sent another communication on [DATE], for 1 of 3 sampled residents, Resident #1.
July 8, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to implement an effective infection control program as evidenced by the facility failed to follow recommendations by the Centers for Disease Control (CDC) and failed to follow through with N95 mask recommendations by the Florida Department of Health (DOH) after 3 visits by DOH were made to the facility following a COVID-19 outbreak, affecting 3 of 5 Personal Protective Equipement (PPE) linen carts on the first and 2nd floor of the facility.
April 25, 2024Standard inspection · 5 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide assistance during dining for 1 of 2 sampled residents reviewed for nutrition (Resident #44).
- D
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 address a skin rash for 1 of 1 resident sampled for skin condition, Resident #97; and failed to address new symptoms of a Urinary Tract Infection in a timely manner for 1 of 1 sampled resident, Resident #59.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interviews, record, and policy review; the facility failed to maintain physician oversight for worsening pressure wounds for 1 of 1 sampled resident reviewed for pressure wounds, Resident #64.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to timely identify residents with malnutrition status and provide nutritional interventions, which resulted in weight loss and pressure ulcer development for 1 of 4 sampled residents, Resident #64, reviewed for tube feeding (GT).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interviews, policy and record review, the facility failed to limit a new order for a psychotropic drug used on a PRN (as needed) basis for 1 of 5 sampled residents reviewed for unnecessary medication review, Resident #156.
February 9, 2023Standard inspection · 7 citations
- D
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 and interviews, the facility failed to maintain a clean, sanitary, homelike environment for the residents in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist a resident during dining for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADL), Resident #16.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, interviews and record review, the facility failed to provide podiatry care in a timely manner for 1 of 1 sampled resident reviewed for Podiatry Care, Resident #100.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the E-kit (emergency medications kit), kept in the locked medication room refrigerator, had not expired medications for 1 of 2 medication storage room's refrigerator reviewed on the C-wing.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure dental care was provided to 1 of 1 sampled resident reviewed for dental services, Resident #70.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations, and interviews, the facility failed to dispose of refuse in a sanitary and timely manner to prevent overflowing of the debris.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, interviews and record review, the facility failed to keep the laundry room in a safe, clean, operating condition, during tour of the laundry room.
Fire safety inspections
10 fire safety citations on file: 3 on August 27, 2025, 6 on April 25, 2024, 1 on February 9, 2023.
Every fire safety citation10 citations
- 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 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · August 27, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 25, 2024 · 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 · April 25, 2024 · 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 · February 9, 2023 · Corrected (the home has a date of correction)