Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Arbor Springs during CMS and state inspections, most recent first.
A resident with multiple mental health diagnoses was transferred to a sister facility over 100 miles away primarily for more lenient smoking times, without documented interdisciplinary discharge planning, resident consent, or a written physician order. Staff interviews gave conflicting reasons for the move, and social services reported no involvement despite facility policy requiring interdisciplinary planning and review with the resident. The resident reported being told abruptly to pack and leave, stated he never signed discharge forms, and said his family and support system remained in his original city, contrary to statements that the transfer would place him closer to family. Records showed no smoking-related care plan, no documented noncompliance with the smoking policy, no exploration of closer placement options, and no evidence that the resident’s preferences and psychosocial needs were considered in the discharge decision.
Two residents were transferred to other SNFs without receiving the required 30-day written notice and without clear evidence of consent or proper discharge orders. In one case, a resident was moved the day after receiving notice, the discharge form lacked the resident’s signature, the resident reported never signing any forms and being told abruptly to pack and leave, and record review showed no MD order for discharge. In the other case, a resident’s daughter/POA reported she was told transfer was only a possibility, was not called back before the move, and later learned the resident was already on the bus; she also reported missing belongings and that the resident was unprepared and unaware the move was permanent. Facility leadership acknowledged that same-day notice was used when a resident was considered agreeable and that a verbal MD order for transfer had been given, despite a written policy requiring interdisciplinary discharge planning and prior review of the discharge plan and proposed date with the resident or representative.
Surveyors found multiple instances of improper labeling and storage of medications on several medication carts, including unlabeled medication cups with tablets, opened insulin vials without open or expiration dates, expired insulin, and ophthalmic solutions lacking required dating. Several unopened insulin vials and other medications labeled by the pharmacy to be refrigerated until opened were instead stored on medication carts. Multiple RNs and LPNs acknowledged during interviews that medications should be labeled with open or expiration dates, expired medications should not remain on carts, and products requiring refrigeration should be kept in a refrigerator, contrary to what was observed. Facility policies require medications to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed and refrigerated medications maintained at appropriate temperatures.
The facility did not ensure a safe and homelike environment when it failed to repair broken wall tiles in a shower room. A resident reported catching a toe on a missing tile, and surveyors later observed seven broken tiles on a shower room wall, including chipped tiles with sharp edges and deteriorating grout. The Maintenance Assistant acknowledged the tiles were in disrepair and stated that daily shower room tours had not yet included this room that day, despite a facility policy requiring daily rounds to identify and address physical plant hazards.
Nursing staff failed to follow the facility’s hand hygiene policy during multiple medication passes. An RN and an LPN repeatedly prepared medications at the cart, popped pills from blister packs into their bare hands, and entered resident rooms without performing hand hygiene. They touched overbed tables, bed controls, and residents, donned gloves without prior hand hygiene, obtained BPs, and administered medications, sometimes moving directly from one resident to another without cleaning their hands, despite a policy requiring hand hygiene before and after patient care and after contact with inanimate objects in the patient vicinity.
The facility did not provide written notification to residents and their representatives regarding transfers to the hospital, instead giving all transfer documents to EMS and only verbally informing residents of the reason and destination. Multiple LPNs and the DON confirmed this practice, and clinical records lacked documentation of written notification.
A resident with a multi-drug-resistant organism (MDRO) urinary tract infection was placed on contact isolation, requiring staff to use PPE when entering the room. Observation showed a CNA entered the room and handled personal items without donning gown or gloves, despite clear signage and available PPE. Interviews revealed staff misunderstanding of contact precaution requirements, contrary to facility policy and physician orders.
A resident's MDS assessment did not accurately reflect their prescribed controlled carbohydrate, no added salt diet, as indicated by a physician's order. Staff interviews confirmed the discrepancy and the need for the MDS to be updated to match the resident's actual nutritional status.
Two residents did not receive IV therapy care according to professional standards and facility policy. One resident's midline catheter dressing was not changed as required, with dried blood and a compromised dressing observed days after insertion. Another resident had a midline catheter inserted in error due to a misunderstanding of medication orders, resulting in an unnecessary invasive procedure. Staff interviews and documentation confirmed lapses in following orders and established protocols.
A resident with a history of UTIs and a suprapubic catheter was started on Ertapenem for a suspected UTI without clinical or laboratory evidence to support the diagnosis. Despite the absence of fever and normal lab values, the antibiotic was continued after a urine sample was not collected, and no urinalysis or culture was performed. Facility staff acknowledged the failure to obtain the necessary labs and to discontinue the antibiotic in the absence of infection.
A resident with complex medical needs was started on Ertapenem for a suspected UTI without supporting clinical evidence or laboratory confirmation. Despite orders for urinalysis and urine culture, no samples were collected, and the antibiotic was continued without follow-up or discontinuation. Staff interviews confirmed that the facility's antibiotic stewardship policy was not followed, resulting in unmonitored antibiotic use.
A resident with chronic respiratory conditions was observed receiving oxygen at 2 liters per minute, contrary to the physician's order of 5 liters per minute with humidification. The DON confirmed the discrepancy, highlighting the need for staff to verify and follow physician orders.
The facility did not post daily nurse staffing information as required. On observation, the staffing information in the lobby was outdated by three days. The Administrator confirmed the expectation for daily updates but admitted there was no policy for posting this information.
A resident with multiple health conditions was unable to be transferred out of bed for three days due to dead batteries in the mechanical lift. Staff reported issues with battery charging and were unable to find charged batteries in other units. The DON was unaware of the problem, and the resident remained in bed due to the equipment malfunction.
The facility failed to maintain a clean environment, with multiple observations of dead pests and cobwebs in residents' rooms. Residents expressed dissatisfaction with the presence of bugs, and the housekeeping staff acknowledged the issue. The Housekeeping Supervisor noted that rooms should be cleaned daily, but the facility's approach to pest control may have contributed to the problem.
A resident with pressure ulcers did not receive the ordered dietary supplement, Juven, on multiple occasions. The LPN and dietician were unaware of its unavailability and did not inform the physician. The DON emphasized the importance of following physician orders and notifying them if orders cannot be fulfilled.
A resident fell while transferring from a wheelchair to a bed due to malfunctioning bed locks. Despite previous reports of bed issues, the facility lacked a routine maintenance schedule and staff awareness regarding bed safety checks. The Director of Nursing confirmed no corrective actions or staff education were initiated following the incident.
The facility failed to ensure proper hand hygiene and infection control practices during medication administration, wound care, and other resident care activities. Staff did not follow enhanced barrier precautions for residents with indwelling medical devices and wounds, and there was a lack of signage and PPE availability. These deficiencies were observed across multiple staff members and residents, leading to potential risks of infection.
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. Nurses did not verify tube or catheter placement, flush between medications, or follow proper procedures for crushing and administering medications. Additionally, a resident was observed self-administering medication left at their bedside.
The facility failed to provide appropriate wound care for multiple residents, including not changing dressings daily as ordered and not following proper infection control procedures. Residents reported and observations confirmed that wound care was often neglected, leading to improper wound management.
The facility failed to provide appropriate enteral nutrition care for two residents. One resident received incorrect feeding and flush rates, while another had outdated gastric tube dressings and was not evaluated for the necessity of the feeding tube despite consuming food and medication orally.
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. Multiple instances of missing documentation were observed, and staff interviews confirmed that care was not documented as required.
The facility failed to develop a comprehensive care plan for a resident who only speaks Spanish, resulting in communication difficulties. The resident's primary language was noted in the MDS, but this information was not included in the care plan, contrary to the facility's policy and procedures.
The facility failed to provide appropriate respiratory care for two residents. One resident received incorrect oxygen levels, and an LPN did not follow sterile technique during a tracheal suctioning procedure. Another resident received oxygen via nasal cannula instead of the prescribed tracheostomy collar.
Failure to Conduct Resident-Centered, Planned Transfer and Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, orderly, and person-centered transfer/discharge for a resident with significant mental health diagnoses, including major depressive disorder, brief psychotic disorder, other specified persistent mood disorders, and generalized anxiety disorder. The resident was discharged to another skilled nursing facility located approximately 115 miles away from the current facility, in a different city from the resident’s identified family and support system. The Nursing Home Transfer and Discharge Notice listed the reason for transfer as access to more frequent/lenient smoking times, was signed by the DON and an APRN, and showed the resident’s name printed but no resident signature. Record review showed no evidence that the resident or a resident representative participated in the discharge decision-making process, no documentation that the resident consented to the transfer, and no documentation that the resident’s preferences and psychosocial needs were considered. Staff interviews revealed inconsistent and incomplete information regarding the rationale for the discharge and the process followed. The LPN Unit Manager stated she was not sure why the resident was discharged but believed it was related to smoking times and reported the resident was told only the day before that he was leaving. The DON and Administrator both stated the resident was transferred because the receiving facility had more lenient smoking times, and the Administrator stated that smokers had been discharged to sister facilities for this reason and that residents were “fine with going.” The Assistant DON reported that the resident was given notice and that she was told the resident was fine with the transfer, but she did not speak with the resident personally. The Director of Social Services reported no involvement in the discharge, noted that residents should consent and sign the discharge notice, and stated she began working at the facility shortly before the discharge date. Another APRN stated the resident was transferred because he wanted to be closer to family and have more lenient smoking access, but also stated she found this strange because she believed the resident did not smoke. Record review and interviews also showed multiple process failures related to discharge planning and documentation. The resident’s smoking assessment documented that the resident currently smoked and did not wish to quit, but the care plan contained no smoking-related focus or interventions, and there was no documentation of noncompliance with the facility’s smoking policy. The facility’s own smoking schedule showed multiple supervised smoking times throughout the day, and the Administrator and Medical Director both referenced smoking restrictions and recent safety mag locks on doors as reasons the resident’s needs could not be met, yet there was no documentation that alternative, closer placement options were explored or that the resident met regulatory criteria for discharge due to the facility’s inability to meet needs. The Medical Director stated he gave a verbal order for transfer but was unsure why the resident was transferred and did not know if other interventions were tried. Review of physician orders showed no written discharge order, and the ADON confirmed there were no discharge or transfer orders in the record. The facility’s Interdisciplinary Discharge Planning policy required development and ongoing review of an interdisciplinary discharge plan and review of the plan and proposed discharge date with the resident or representative, but the record lacked evidence that an effective discharge plan was developed or implemented. The resident reported that he was abruptly informed by a nurse to pack his belongings and leave after breakfast, was transported in a minivan without having signed any discharge forms, and believed someone else signed his discharge form. He stated he had family, including a daughter, grandchildren, and fiancée, living in his original city and that he was not closer to them after the transfer, contrary to what he reported the DON had told him. He described feeling sad and depressed at the new facility, reported he was not allowed to go outside, and stated he thought the transfer was retaliation for complaints he had made about CNAs sleeping. The Administrator stated that if a resident is agreeable to go somewhere else, discharge notice can be given on the same day, and acknowledged there should be a doctor’s order for transfer. The Administrator also stated he did not know whether the receiving facility actually had more liberal smoking policies. Overall, the documentation and interviews showed the facility failed to involve the resident in discharge planning, failed to document consent and appropriate orders, failed to explore closer placement options, and based the transfer primarily on smoking policy without demonstrating inability to meet the resident’s needs in accordance with facility policy and regulatory requirements. The resident’s account and the lack of documentation of involvement of social services, therapy, or an interdisciplinary team in planning the discharge further demonstrate that the facility did not follow its Interdisciplinary Discharge Planning policy. The policy required that discharge needs and goals be developed upon admission, monitored by the interdisciplinary team, and reviewed with the resident or representative prior to discharge, including the proposed discharge date. In this case, the Director of Social Services reported no involvement, the APRN stated she relied on social services and therapy for discharge readiness but was not involved in notice timing, and there was no evidence in the record of an interdisciplinary review of the discharge plan. The facility also failed to document that the resident’s stated goals, family location, or psychosocial status were considered in determining the discharge destination, despite the resident’s mental health diagnoses and his report that his family and support system remained in the original city. These combined actions and omissions led to a transfer that did not demonstrate alignment with the resident’s needs and preferences and lacked the required planning, documentation, and resident participation.
Failure to Provide Timely Written Transfer/Discharge Notice and Obtain Proper Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of transfer or discharge at least 30 days in advance and to obtain appropriate consent and orders for two residents. For one resident, the Nursing Home Transfer and Discharge Notice showed a transfer to another skilled nursing facility on 2/20/2026, with the notice provided on 2/19/2026 and an effective date of 2/20/2026. The form was signed by the Director of Nursing and an APRN, but the resident’s signature line was blank. The resident reported being told abruptly by a nurse to pack belongings and leave after breakfast, stated they never signed any forms, and asserted that the signature on the discharge form was not theirs. Record review showed no physician order for discharge or transfer, and the Assistant Director of Nursing confirmed there were no such orders for this resident. The Director of Social Services stated that if a resident is being transferred to another facility, they would need to consent and sign the discharge notice. For another resident, the Nursing Home Transfer and Discharge Notice documented a same-day notice and transfer to a facility closer to the resident’s daughter, with the notice provided and effective on the same date. The resident’s daughter/POA reported she had no advance notice before the transfer, was initially told transfer was only a possible option, and that she wanted to discuss it with the resident before any move occurred. She stated no one called her back, and when she attempted to follow up, the resident was already on the bus being transferred. She also reported that many of the resident’s belongings did not accompany the resident, that she was told all belongings were in one box at the receiving facility, and that the resident was not prepared for the transfer and did not realize it was permanent. The Administrator stated that if a resident is agreeable to go somewhere else, discharge notice can be given on the same day, and that there should be a doctor’s order for transfer, indicating a verbal order had been given by the Medical Director to the DON. The facility’s Interdisciplinary Discharge Planning policy required that discharge needs, goals, and estimated length of stay be developed upon admission, that progress toward discharge goals be monitored and plans revised as appropriate, and that the discharge plan, including the proposed discharge date, be reviewed with the resident or representative prior to discharge.
Improper Labeling and Storage of Insulin and Other Medications on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals, particularly insulin and ophthalmic solutions, were properly labeled, stored, and maintained in accordance with professional standards and facility policy. During observation of medication cart #1 with an RN, surveyors found two unlabeled medication cups containing multiple tablets, as well as several insulin vials that were either opened without a date or expired, and multiple unopened insulin vials labeled by the pharmacy to be refrigerated until opened but stored on the cart instead. The RN acknowledged that medications should not be unlabeled, should not be pre-poured and left on the cart, and that insulin requiring refrigeration should not be kept on the cart and that expired insulin should not be present. On medication cart #2, observed with an LPN, surveyors identified an unopened Lispro insulin that should have been refrigerated until opened and multiple Latanoprost and Timolol ophthalmic solutions that were either missing open dates or expiration dates, with the LPN stating that all medicines should be in the refrigerator if required, labeled with open dates, and removed if expired, and acknowledging that the eye drops were expired. On medication cart #4, another LPN was observed with Lantus and Novolin insulin vials that lacked open dates or expiration dates, along with an unopened Lantus insulin that should have been refrigerated until opened; the LPN stated that all medications should have open or expiration dates and remain refrigerated until needed. On medication cart #5, surveyors found multiple unopened insulin vials labeled to be refrigerated until opened stored on the cart, an opened Lantus insulin without pharmacy packaging or resident identification and without open or expiration dates, an opened Aspart insulin without dates, and two expired insulin vials with documented open dates; the LPN confirmed there should not be expired medicines on the cart and that insulins should be labeled and refrigerated when not in use. Further observations on medication carts #6 and #7 revealed additional issues with insulin storage and labeling. On cart #6, there were unopened Aspart and Lantus insulin vials labeled to be refrigerated until opened and an opened Lispro insulin without an open date or expiration date; the LPN stated that every insulin should have an open or expiration date and that unused insulin should remain in the refrigerator. On cart #7, surveyors found an expired Lispro insulin with an open date, unopened Glargine and Humulin insulins that were labeled to be refrigerated until opened but stored on the cart, and an opened Novolin insulin without an open date or expiration date; the LPN stated that every insulin needs expiration dates and unopened insulins should stay in the refrigerator. Review of facility policies confirmed that medications are required to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed, and that medications requiring refrigeration must be stored at 2–8°C (36–46°F).
Failure to Maintain Safe and Intact Shower Room Surfaces
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment when it did not repair broken and damaged wall tiles in a resident shower room. A resident reported that there was a missing shower tile in the shower room and that she caught her toe on it in January. On observation of the 400's hall shower room, surveyors noted seven broken wall tiles on the wall adjacent to the door, including two tiles that were chipped with sharp edges exposed and an uneven surface with deteriorating grout. During interview, the Maintenance Assistant acknowledged that the tiles were in disrepair and stated that he tours the shower rooms daily but had not yet toured this particular shower room that day. Review of the facility’s Maintenance policy, last approved on 01/15/2026, showed that the Director of Environmental Services is responsible for daily rounds of the building to ensure the physical plant is free of hazards and in proper condition, indicating that the damaged tiles were not identified and corrected as required by the facility’s preventive maintenance procedures.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring staff performed required hand hygiene during medication administration. During multiple observations of medication passes, a Registered Nurse (Staff A) and a Licensed Practical Nurse (Staff C) repeatedly approached and used the medication cart, unlocked it, activated and typed on the computer, and prepared medications without performing hand hygiene. Staff A was observed popping multiple medications from blister packs directly into their bare hand before placing them into medication cups for several residents, and then entering resident rooms without hand hygiene, touching overbed tables, bed controls, and residents, and donning gloves without prior hand hygiene before taking blood pressures and administering medications. Staff A acknowledged during interview that they should not have touched the medications with their hands and should have used hand sanitizer more frequently. Similarly, Staff C was observed returning to the medication cart multiple times, unlocking it, activating and typing on the computer, and preparing medications for several residents without performing hand hygiene. Staff C then entered resident rooms without hand hygiene, touched overbed tables, bed controls, and residents, obtained blood pressures, and administered medications, and in some instances exited rooms and immediately began preparing medications for other residents without performing hand hygiene. During interview, Staff C stated they should have used the hand sanitizer available on the cart. Review of the facility’s “Hand Hygiene” policy, last approved on 1/15/2026, showed that hand hygiene is required before and after patient care and after contact with inanimate objects in the immediate patient vicinity, which was not followed in these observed instances.
Failure to Provide Written Transfer Notification to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers, for three residents reviewed for discharge or transfer. Clinical records for each resident contained transfer forms and discharge notices indicating the date and destination of the transfer, but there was no documentation that written notification was given to the residents or their representatives. Instead, staff reported that all transfer documents were provided to EMS, and only verbal explanations were given to the residents about the reason for transfer and the destination. Interviews with multiple LPNs and the Director of Nursing confirmed that the practice was to verbally inform residents of the transfer and provide all paperwork to EMS, rather than directly to the residents or their representatives. Staff also indicated that they did not provide written documentation to residents at the time of transfer, citing concerns that the paperwork might get lost. The facility's policy stated that transfers or discharges should be safe, orderly, and appropriate to meet the needs of the resident, but did not specify the process for written notification to residents or their representatives.
Failure to Follow Contact Precaution Protocols for Resident with MDRO UTI
Penalty
Summary
Staff failed to follow established infection control standards for transmission-based precautions for a resident admitted with a diagnosis of pseudomonas aeruginosa urinary tract infection, a multi-drug-resistant organism. Physician orders and facility policy required contact isolation, including the use of personal protective equipment (PPE) such as gowns and gloves upon entering the resident's room. Observation revealed that a CNA entered the resident's room without donning any PPE, despite clear signage and readily available PPE at the door. The CNA handled the resident's personal belongings on the bedside table and then exited the room without wearing gloves or a gown. Interviews with the CNA, LPN supervisor, and Director of Nursing confirmed that staff were expected to wear appropriate PPE when entering rooms under contact precautions. The CNA stated a misunderstanding of the requirements, believing PPE was only necessary when directly caring for the resident, not when entering the room or handling items. Facility policy and posted signage both specified that gloves and gowns must be worn upon entry to the room, regardless of the nature of the visit, to prevent the spread of infection.
Inaccurate MDS Assessment of Resident's Therapeutic Diet
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the nutritional status of a resident. Specifically, the annual Minimum Data Set (MDS) for one resident indicated that the resident was not on a therapeutic diet, as documented under Section K - Swallowing/Nutritional Status. However, a physician's order dated several months prior specified that the resident was to receive a controlled carbohydrate diet with no added salt. During interviews, the MDS Coordinator acknowledged that the MDS would need to be modified to reflect the resident's actual diet, and the Director of Nursing confirmed that the MDS should accurately represent the resident's information.
Failure to Follow IV Therapy Standards and Orders for Two Residents
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents receiving IV therapy. For one resident, a midline catheter was inserted in the left upper arm for IV fluids, but the transparent dressing over the insertion site was observed to be lifting at the edges, with dried blood visible on gauze beneath the dressing. The dressing was dated nine days prior and had not been changed as required by both physician orders and facility policy, which specify dressing changes every 5-7 days or sooner if compromised, and every 48 hours if gauze is present. Staff interviews confirmed the dressing should have been changed, and the resident reported it had not been changed since insertion. Another resident had a midline catheter inserted in error after staff misinterpreted medication orders, believing IV access was needed for antibiotic administration. The resident received all doses of the prescribed medication intramuscularly, as originally intended, and the midline was removed the following day after the mistake was identified. Documentation and staff interviews revealed that the midline was not used for medication administration, and the error was due to a misunderstanding of the medication route. The advanced practice provider confirmed that no order was given for IV administration or midline insertion. Facility policy requires a provider order and written consent for midline or PICC insertion, and specifies dressing change intervals to prevent infection. In both cases, the facility did not follow its own policies or professional standards, resulting in improper catheter care and an unnecessary invasive procedure.
Unnecessary Antibiotic Use Without Laboratory Confirmation
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) and a suprapubic catheter was started on Ertapenem, a broad-spectrum antibiotic, for a suspected UTI without adequate clinical indications or supporting laboratory evidence. The physician ordered a urinalysis with reflex culture, but the urine sample was not collected, and no urinalysis or urine culture results were documented. Despite the absence of fever, normal white blood cell count, and lack of other clinical signs of infection, the antibiotic regimen was continued. Interviews with facility staff, including the Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse, confirmed that the antibiotic should not have been continued without laboratory confirmation of infection. Staff acknowledged that there was a failure to follow up on obtaining the necessary urine sample and to discontinue the antibiotic in the absence of supporting evidence. This resulted in the resident receiving unnecessary antibiotics, contrary to facility policy and best practices for antimicrobial stewardship.
Failure to Monitor and Manage Antibiotic Use per Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not adequately monitoring and managing the use of antibiotics for a resident with multiple complex medical conditions, including quadriplegia, tracheostomy, and a history of urinary tract infections (UTIs). The resident was started on Ertapenem for a suspected UTI based on a physician's order, despite the absence of clinical signs such as fever or elevated white blood cell count. Although a urinalysis and urine culture were ordered, no samples were successfully collected, and there were no laboratory reports or follow-up orders for these tests during the relevant period. Staff interviews revealed that the antibiotic was continued without confirmation of infection, and there was a lack of follow-up to obtain the necessary urine sample or to discontinue the antibiotic in the absence of supporting evidence. The Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse all acknowledged that the facility's antibiotic stewardship policy was not followed, as antibiotics were administered empirically without culture results or clear clinical indications, and appropriate communication and documentation were lacking.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident received the correct oxygen flow rate as prescribed by their physician. During observations, it was noted that the resident was receiving oxygen at a flow rate of 2 liters per minute via a tracheostomy mask, despite the physician's order specifying a flow rate of 5 liters per minute with humidification. The resident, who was admitted with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and sleep apnea, was not receiving the prescribed level of oxygen. The Director of Nursing confirmed that the resident's oxygen flow rate was incorrect and emphasized that staff should review and verify physician orders to ensure compliance with prescribed treatments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis. During an observation on February 6, 2025, at 8:45 AM, it was noted that the nurse staffing information displayed in the front lobby was outdated, showing the date of February 3, 2025. In an interview conducted on the same day at approximately 9:00 AM, the Administrator acknowledged that the expectation was to have the staffing information posted and readily available with the correct information at the beginning of each shift. However, it was revealed that the facility did not have a policy in place for posting the nurse staffing information.
Failure to Transfer Resident Due to Equipment Malfunction
Penalty
Summary
The facility failed to ensure that a resident was transferred out of bed using a mechanical lift, as required by their care plan. The resident, who had multiple diagnoses including type 2 diabetes mellitus, hypertension, obesity, and a history of cerebrovascular accident, was unable to be transferred out of bed for three consecutive days due to dead batteries in the Hoyer lift. The resident expressed that the lift had dead batteries from Friday to Sunday, preventing them from getting out of bed. Interviews with staff members revealed that there was an ongoing issue with the batteries not charging properly. Staff members attempted to find charged batteries by checking other units but were unsuccessful. The Director of Nursing was unaware of the battery issue and stated that staff were expected to obtain batteries from other areas if needed. Despite these expectations, the resident remained in bed due to the lack of functioning equipment.
Facility Fails to Maintain Clean Environment Due to Pest Presence
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of dead pests and cobwebs in several residents' rooms. During an observation, a dead brown small pest was found in a cobweb high on the wall in a resident's room. The resident expressed dissatisfaction with the presence of bugs in their room. Another resident's room had peeling baseboards with multiple dead pests inside, as well as cobwebs containing dead pests on the walls and above the windows. This resident reported seeing live bugs, particularly in the bathroom, and expressed uncertainty about whether the facility had conducted pest control measures. The housekeeping staff, including a housekeeper and the Housekeeping Supervisor, acknowledged the presence of dead pests in cobwebs during their observations. The Housekeeping Supervisor confirmed that the rooms should be cleaned and dusted daily, with cobwebs and bugs removed regularly. He noted that the facility was treating one hall at a time, which might have contributed to the issue of bugs in some rooms. The observations and interviews indicate a failure to provide a clean and safe environment for the residents, as required by regulations.
Failure to Administer Dietary Supplement as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement, Juven, as ordered for a resident with pressure ulcers, paraplegia, muscle wasting, and atrophy. The physician's orders specified that Juven should be administered twice daily, but the Medication Administration Record showed that it was not given on several occasions. There was no documentation indicating that the physician or nutritionist was informed about the unavailability of the supplement. Interviews revealed that the resident expressed concern about not receiving the supplement, which was intended to aid in wound healing. Staff members, including an LPN and the dietician, confirmed that they were unaware of the supplement's unavailability and did not notify the physician. The Director of Nursing stated that physician orders should be followed, and any inability to do so should be communicated to the physician.
Failure to Maintain Bed Safety Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not maintaining the functionality of the bed locks, which led to an accident. A resident, who had a history of independently transferring from a wheelchair to a bed, reported that the bed was not locked, causing it to move and resulting in a fall. The resident had previously reported issues with the bed, including a malfunctioning lock and problems with the bed not lowering, which were documented in work orders. Despite these reports, there was no evidence of a routine maintenance schedule to check the beds for safety, and the maintenance director confirmed that checks were only performed when issues were reported by residents or staff. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness and responsibility for checking bed functionality. The Director of Nursing acknowledged that no corrective plan was initiated after the bed malfunction was identified, and no routine checks or staff education on bed safety were implemented. This lack of proactive measures and communication contributed to the unsafe environment that led to the resident's fall.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration, wound care, and other resident care activities. Multiple observations revealed that staff members, including RNs and LPNs, did not wash their hands or use hand sanitizer before and after administering medications, handling medical equipment, or performing wound care. This was observed across several residents, including those with complex medical needs such as gastrostomy tubes, tracheostomies, and stage 4 pressure ulcers. Staff members admitted to not following hand hygiene protocols during interviews, and the facility's policies clearly outlined the necessity of hand hygiene to prevent the spread of infection. The facility also failed to implement enhanced barrier precautions for residents with indwelling medical devices and wounds. Observations showed that there was no signage indicating enhanced barrier precautions, and PPE supplies were not available in or near the rooms of affected residents. Staff members did not don gowns when providing high-contact care activities, such as wound care, tracheostomy care, and medication administration via gastrostomy tubes. Interviews with staff revealed a lack of awareness and adherence to the enhanced barrier precautions, despite physician orders and care plans indicating the need for such measures. Additionally, the facility did not follow proper infection control standards during wound care procedures. Staff members were observed not cleaning overbed tables before placing wound care supplies, not performing hand hygiene between glove changes, and contaminating sterile supplies by touching non-sterile surfaces. These actions were contrary to the facility's policies on dressing changes and wound care, which emphasized the importance of maintaining a sterile environment to promote healing and prevent infections. The Director of Nursing acknowledged the deficiencies and stated that staff should follow the established policies and procedures for infection control.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. During an observation, a registered nurse administered medications to a resident with an enteral tube without verifying tube placement, flushing between medications, or using gravity flow. The nurse admitted to not following the facility's policy, which requires checking for gastric residual volume and flushing the tube with water between each medication. Another incident involved a resident with a midline catheter where the nurse did not properly clean the needleless connector, verify catheter placement, or assess the insertion site before administering IV medication. The Director of Nursing confirmed the lack of a specific central line flush policy and expected procedures were not followed. Additionally, a resident was observed self-administering medication left at their bedside, which is against facility policy. Another nurse was seen crushing and administering multiple medications together via a gastric tube, contrary to the policy that requires each medication to be crushed and administered separately. The Director of Nursing acknowledged that the staff did not adhere to the proper procedures for medication administration via enteral tubes and that medications should not be left at the bedside for residents who are not capable of self-administration.
Failure to Provide Appropriate Wound Care
Penalty
Summary
The facility failed to ensure that residents received wound care treatment in accordance with professional standards of practice. Resident #91, who had a stage 4 pressure ulcer, did not receive daily wound care as ordered by the physician. The dressing was observed to be dated incorrectly, and there were multiple days where no entries were documented in the Treatment Administration Record. Additionally, a family member had to perform wound care due to the facility's inaction, and staff failed to follow proper infection control procedures during care observations. Resident #73 had a left heel dressing that was not changed daily as required. The resident reported that staff often forgot to change the dressing, and observations confirmed that the dressing was not changed for several days. Staff interviews corroborated that the dressing should have been changed daily but was not. Resident #133 and Resident #155 also did not receive appropriate wound care. Resident #133's right thigh dressing was not changed daily as ordered, and the resident reported that staff had not attended to the wound care as required. Resident #155 had a surgical wound with a dressing that was not changed according to the physician's orders, and the wound vac was not applied due to a lack of supplies. The facility's documentation and staff interviews confirmed these deficiencies in wound care treatment.
Failure to Ensure Appropriate Enteral Nutrition Care
Penalty
Summary
The facility failed to ensure appropriate care and services for enteral nutrition for two residents. For Resident #96, observations revealed discrepancies between the physician's orders and the actual administration of the feeding and flush rates. The resident's feeding machine was found beeping with empty formula and water bags, and the feeding rate was consistently observed at 50 ml/hr, contrary to the physician's order of 55 ml/hr. Additionally, the autoflush rate was running at 60 ml/hr instead of the ordered 40 ml/hr. The resident experienced a slight weight loss, which the Registered Dietician noted could be affected by the incorrect feeding rate. The Director of Nursing confirmed that nurses should verify the orders and the milliliters that a feeding and flush should be running. For Resident #151, the facility failed to change the gastric tube dressing as per the physician's orders. The resident's tube feeding dressing was observed to be dated several days prior, and the resident reported that the dressing had not been changed for days. The resident also mentioned that they no longer needed the feeding tube as they were consuming food and medication orally. Physician orders indicated a regular diet and daily dressing changes, which were not followed. The Director of Nursing acknowledged that the resident should have been evaluated earlier and that the dressing should be changed daily according to physician orders.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. For Resident #91, there were multiple instances where wound care and tracheostomy care were not documented in the Treatment Administration Record (TAR) for May 2024. This included missing entries for cleansing and dressing the coccyx and tracheostomy site, as well as suctioning the tracheostomy tube. Similarly, Resident #260's TAR showed missing documentation for wound care and enteral tube care on several dates in May 2024. Resident #73's TAR also lacked documentation for wound care on specific dates in May 2024. During an interview, a Licensed Practical Nurse (LPN) confirmed that all wound care should be documented, and the Director of Nursing (DON) stated that nurses should follow accepted standards for documentation. Resident #133's right thigh dressing was observed to be dated incorrectly, and the TAR showed discrepancies in the administration of care. The DON confirmed that staff should follow physician orders for treatment. Resident #151's tube feeding dressing was observed to be outdated, and the resident reported that the dressing had not been changed for days. The TAR showed staff initials for care that was not provided. Resident #155 had a visibly soiled abdominal wound dressing, and the TAR showed missing entries for wound care. The DON stated that nursing staff should document accurately and as needed in the resident treatment record.
Failure to Develop Comprehensive Care Plan for Language and Communication
Penalty
Summary
The facility failed to develop a comprehensive care plan for language and communication for a resident who only speaks Spanish. During an interview, the resident expressed difficulty in communicating with staff due to the language barrier. The resident's Medicare 5-Day Minimum Data Set (MDS) indicated that Spanish was the resident's primary language, but this information was not included in the resident's care plan. This omission was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident's communication needs were not addressed in the care plan. The facility's policy and procedures for developing care plans require that an individualized, person-centered plan of care be established by the interdisciplinary team (IDT) and updated in accordance with state and federal regulatory requirements. The policy also mandates that the care plan should include measurable objectives and timetables to meet the resident's needs. Despite these requirements, the care plan for the resident did not address the language and communication needs, leading to a deficiency in providing appropriate care for the resident's specific needs.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care services for two residents. Resident #91, who was admitted with acute and chronic respiratory failure and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations on multiple occasions showed the resident receiving oxygen at 5 liters per minute. Additionally, during a tracheal suctioning procedure, an LPN did not follow sterile technique and failed to assess breath sounds before and after the procedure, contrary to the facility's policy and procedures for suctioning ventilator-dependent residents. Resident #96, who had a history of pneumonia, interstitial pulmonary disease, respiratory failure, and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations showed the resident receiving oxygen at 3 liters per minute via nasal cannula. The care plan for Resident #96 indicated the need for oxygen administration as ordered, but staff failed to ensure the correct oxygen rate was administered. The DON confirmed that staff should check and adjust the oxygen rate to match the physician's order.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ocala Health And Rehabilitation Center | 0.2 mi | — | 10 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 0.9 mi | — | 0 | 0 |
| Avante At Ocala, Inc | 1.1 mi | — | 1 | 0 |
| Palm Garden Of Ocala | 3 mi | — | 1 | 0 |
| Life Care Center Of Ocala | 3.2 mi | — | 8 | 0 |
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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 August 2026) and official state health department websites.