Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Blue Lake Post Acute during CMS and state inspections, most recent first.
Eight residents were found to have long, thick, and discolored toenails, with several reporting pain and discomfort, and none had current or past podiatry care orders. Staff interviews revealed unfamiliarity with nail care policies, lack of documentation, and delays in arranging podiatry services, resulting in residents not receiving necessary foot care.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment. Despite known behavioral issues and previous orders for increased monitoring, staff failed to provide adequate supervision, resulting in inappropriate sexual contact. Care plans and interventions were not updated promptly, and administrative follow-up was delayed, leaving the resident and others at risk.
A female resident with severe cognitive impairment and behavioral issues was found in another resident's bed with her pants unbuttoned, while a male resident stood beside her with his hand inside her pants. Staff failed to maintain adequate supervision despite escalating inappropriate interactions. The facility's investigation was incomplete and inconsistent, with missing or inaccurate witness statements and a lack of timely interviews. Care plans and monitoring orders were not promptly updated or implemented for either resident following the incident.
Facility staff failed to provide appropriate supervision and implement necessary interventions to protect a cognitively impaired resident from sexual abuse by another resident. Despite clear behavioral warning signs and physician orders for increased monitoring, staff left the residents unsupervised, resulting in an incident of inappropriate sexual contact. Documentation and investigation of the event were inconsistent, and the administration did not ensure protective measures were in place.
A QAA committee failed to develop and implement effective corrective actions after an incident where a female resident with severe cognitive impairment and behavioral issues was found in a male resident's bed with evidence of inappropriate sexual contact. Staff observed escalating inappropriate interactions but did not maintain adequate supervision, and the facility did not promptly update care plans or communicate with the Medical Director. The QAPI process was not followed as required by facility policy.
The facility did not promptly report allegations of abuse and the results of related investigations to the State Survey Agency as required. In one case, a resident with multiple health issues experienced rough treatment by a CNA, which was not immediately reported as abuse. In another case, two residents were involved in inappropriate sexual behavior, but the incident was not reported within the required timeframe. The facility's actions did not align with its own policy or federal reporting requirements.
The facility failed to prevent contamination of refrigerated food due to an unclean evaporator fan in the walk-in refrigerator. Observations revealed a build-up of dust-like debris on the fan, which was not cleaned over several days. This resulted in a tray of sandwiches being exposed to potential contamination after the plastic wrap was blown off by the fan. The certified dietary manager confirmed the issue and identified the Maintenance Department as responsible for cleaning the fan.
The facility failed to provide documentation for its QAPI program during a review with the Administrator and DON. Despite claims of monthly meetings and performance improvement plans, no evidence was available. The only document provided was an outdated sign-in sheet, and the facility's QAPI policy was not presented.
A facility failed to complete and submit MDS assessments for several residents within the required timeframes. An LPN responsible for these tasks was unaware of the overdue assessments until informed during a survey. The residents affected had complex medical conditions, and the deficiency persisted despite the LPN's efforts to manage the workload.
The facility failed to complete quarterly MDS assessments for four residents, as identified during a review of records and staff interviews. An LPN responsible for assisting with these assessments was unaware of the overdue status until informed, acknowledging the late submissions. The assessments were not completed in a timely manner, affecting the comprehensive evaluation of residents' needs and goals.
A facility failed to notify a resident and her representative in writing about an emergency hospital transfer, and did not inform the LTCO. The resident, with a history of mental health issues, exhibited aggressive behavior leading to an involuntary psychiatric admission. The facility did not provide the required AHCA Transfer/Discharge Notice or notify the LTCO, as confirmed by the Social Services Director.
A facility failed to provide a resident and/or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with multiple mental health diagnoses, was involuntarily admitted to a psychiatric unit due to aggressive behavior. The facility did not document any written notice about the bed-hold policy, as confirmed by the SSD.
The facility failed to refer residents with newly diagnosed serious mental illnesses for PASRR Level II screenings, affecting three residents. A resident with schizoaffective disorder and other mental health diagnoses, another with major depressive disorder and generalized anxiety disorder, and a third with generalized anxiety disorder were not referred for necessary screenings. The Social Services Director noted the absence of a system to review Level I screenings for necessary Level II referrals, despite facility policy requiring such actions upon significant changes in mental health status.
A resident with severe cognitive impairment was found unsupervised, trimming her own toenails despite having a history of onychomycosis and associated pain. The facility lacked an assessment of her ability to safely perform nail care and had no policy on residents' use of nail clippers. Staff were unaware of the resident's possession of clippers and the podiatrist's findings, leading to inadequate supervision and risk of injury.
The facility failed to implement effective infection control practices, as two residents were observed without enhanced barrier precautions (EBP) signage. One resident with a urinary catheter had the collection bag and tubing touching the floor, while another with an enteral feeding tube also lacked EBP signage. Staff interviews revealed inconsistencies in training and communication regarding EBP, highlighting a gap in the facility's infection prevention policy implementation.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide foot care consistent with professional standards of practice for eight residents reviewed. Multiple residents were observed to have very long, thick, and discolored toenails, with some residents reporting pain and discomfort. Interviews with residents and their family members revealed that they had not seen a podiatrist, and photographic evidence was obtained to document the condition of their toenails. Review of medical records and physician's orders for these residents showed no current, past, or discontinued orders for podiatry care, visits, or referrals, except for one resident who had a single podiatry note with no ongoing documentation of foot or toenail care. Staff interviews indicated a lack of familiarity with the facility's nail care policy and procedure. The unit manager stated that while feet are assessed for skin issues, toenail conditions are not documented, and residents with long or damaged toenails are placed on a list for podiatrist visits, which are coordinated by social services. Certified Nursing Assistants reported that they do not cut residents' nails and would report long nails to a nurse. The Social Services Director explained that previous podiatry services required cash payment and that a new contract with a podiatrist had recently been established, but services had not yet started. The appointment book for podiatry visits could not be located when requested. The Director of Nursing confirmed that a new podiatrist had been contracted but was unaware of a start date and was not familiar with the nail care procedure. Overall, the facility did not ensure that residents received necessary foot care or assistance in making appointments with qualified healthcare providers, resulting in multiple residents experiencing prolonged periods without appropriate podiatry care.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident with moderate cognitive impairment. The resident who was unable to consent to sexual activity had a history of aggressive behaviors, severe cognitive deficits, and required significant assistance with personal care. Despite documented behavioral issues and a care plan noting inappropriate sexual advances, the facility did not implement or maintain adequate supervision or interventions to prevent inappropriate contact between the two residents. On the day of the incident, staff observed escalating physical interactions between the two residents, including hand-holding and attempts at physical closeness, but only provided verbal redirection and did not increase supervision. Both residents were left unsupervised for a period, during which time staff later found the resident with severe cognitive impairment in the other resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Documentation revealed that orders for increased monitoring had been discontinued prior to the incident, and there was no evidence of frequent or one-on-one supervision in place at the time of the event. Following the incident, it was noted that care plans and interventions for both residents were not updated in a timely manner to address the risk of further inappropriate contact. The facility's policies required immediate intervention and protection in cases of suspected abuse, but staff interviews and record reviews indicated that administrative follow-up and investigation were delayed. The lack of prompt and effective interventions created an ongoing risk for abuse of the resident and potentially other vulnerable residents.
Failure to Investigate Sexual Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, resulting in a deficiency cited at Immediate Jeopardy level. The incident involved a female resident with severe cognitive impairment, behavioral disturbances, and a history of aggression and wandering, and a male resident with moderate cognitive impairment and no prior behavioral issues. On the day of the incident, staff observed escalating inappropriate interactions between the two residents, including physical contact and attempts to sit together, but did not maintain adequate supervision. Eventually, both residents were found in the male resident's room, with the female resident lying on the bed with her pants unbuttoned and the male resident standing beside her with his hand inside her pants. Both LPNs present at the scene confirmed witnessing this event. The facility's investigation into the incident was incomplete and inconsistent. The Administrator initially failed to obtain statements from all involved staff, provided conflicting information about witness identities, and did not interview the male resident involved. There were discrepancies in the documentation and staff schedules, and the Administrator relied on statements that were later found to be inaccurate or attributed to the wrong individuals. The investigation was not promptly or thoroughly conducted, as required by the facility's own abuse policy, and the Administrator only substantiated the abuse allegation after being confronted with new information from staff interviews days after the incident. Additionally, the facility did not implement or document appropriate supervision or care plan interventions for either resident immediately following the incident. Orders for increased monitoring were either discontinued or not implemented, and care plans were not updated in a timely manner to address the behavioral risks. The lack of a prompt, thorough investigation and failure to ensure resident safety and supervision contributed to the deficiency cited by surveyors.
Failure to Supervise and Protect Resident from Sexual Abuse
Penalty
Summary
Facility administration failed to ensure appropriate supervision and protection of a vulnerable resident from sexual abuse. One resident with severe cognitive impairment, aggressive behaviors, and a history of wandering and inappropriate actions was not provided with consistent monitoring as ordered by physicians. Orders for 1:1 and 30-minute monitoring were inconsistently implemented and, at times, discontinued without documentation of increased or frequent monitoring, leaving the resident unsupervised for extended periods. On the day of the incident, staff observed escalating interactions between two residents, including physical contact and attempts at inappropriate proximity. Despite these warning signs, staff left the area to attend to other duties, resulting in both residents being unsupervised. When staff returned, they found the cognitively impaired resident in another resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Both residents were fully clothed, but the situation indicated inappropriate sexual contact had occurred without adequate supervision or intervention. Interviews and record reviews revealed confusion and inconsistencies in staff documentation, witness statements, and the facility's investigation process. The administration did not ensure that interventions for increased supervision were implemented for either resident following the incident, and there was a lack of clear communication and follow-through regarding abuse investigation and reporting. The failure to provide necessary supervision and to implement protective interventions created a situation of immediate jeopardy for vulnerable residents.
Failure of QAA Committee to Address and Correct Quality Deficiencies Leading to Resident Sexual Abuse
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that resulted in adverse outcomes. This failure was evident in the lack of improvement in systems and processes, which contributed to an incident of sexual abuse involving a female resident with severe cognitive impairment and a male resident. The QAA did not initiate or follow through with performance improvement projects or ad hoc QAPI meetings after the incident, and the Medical Director was not promptly informed of the event or the transfer of the involved male resident. The female resident involved had a history of severe cognitive impairment, aggressive behaviors, and required significant assistance with personal care. Her care plan documented behavioral issues, including aggression and inappropriate behaviors, but monitoring orders were inconsistently implemented and discontinued without documentation of increased supervision. On the day of the incident, staff observed escalating inappropriate interactions between the two residents but did not maintain adequate supervision, resulting in the female resident being found in the male resident's bed with evidence of inappropriate sexual contact. The male resident had moderate cognitive impairment and no prior psychiatric diagnoses or behavioral issues documented before the incident. After the event, his care plan was updated to include interventions for hypersexuality, but there was no intervention for increased supervision from the time of the incident until his transfer. Staff interviews revealed that administrative and clinical leadership did not conduct an ad hoc QAPI meeting or ensure timely communication with the Medical Director. The facility's QAPI policy required proactive and comprehensive quality improvement actions, but these were not followed in response to the incident.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to the appropriate officials, including the State Survey Agency. Additionally, the facility did not report the results of the investigations to the State Survey Agency within five working days of the incidents. These failures were identified in three residents reviewed for abuse out of a total survey sample of eight residents. The reporting requirements under this regulation are based on real (clock) time, not business hours. One resident, who had multiple complex medical conditions including acute respiratory failure, congestive heart failure, diabetes, morbid obesity, and moderate cognitive impairment, was involved in an incident where his family alleged that a CNA was rough and rude while assisting him with toileting. The incident was initially reported by the resident to his family, who then reported it to the facility. The facility's Social Services Director completed a grievance form, but the incident was not immediately recognized or reported as abuse. The Administrator initially considered the matter a customer service issue and did not file an abuse report until confronted by the family, resulting in a delay in reporting the allegation to the State Survey Agency. In another incident, two residents were found in a situation involving likely inappropriate sexual behavior. Nursing staff discovered the incident and separated the residents, notifying the Administrator in Training. However, the facility did not submit the required 5-day federal report until several days after the incident, with the Administrator stating that submission within five business days was considered timely according to their practice. The facility's own policy required reporting of abuse allegations within two hours, but this was not followed in these cases.
Refrigerated Food Contamination Risk Due to Unclean Fan
Penalty
Summary
The facility failed to store refrigerated food in a manner that prevents contamination by airborne matter. During an initial tour of the kitchen, the walk-in refrigerator's evaporator fan was observed with a build-up of thick, dark matter resembling dust on the grates of the fan cover. This debris was moving due to the fan blowing cold air around, posing a risk of contamination to exposed food. A subsequent inspection revealed that the fan remained uncleaned, with visible dust-like debris on all surfaces. A tray of sandwiches in the refrigerator was found with its plastic wrap blown off, exposing the food to potential contamination. The certified dietary manager confirmed the soiled condition of the fan and the risk to the uncovered food, stating that the Maintenance Department was responsible for cleaning the fan.
Lack of Documentation for QAPI Program
Penalty
Summary
The facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. During a QAPI review with the Administrator and the Director of Nursing, no current documentation was provided to verify the development, implementation, and maintenance of an effective, comprehensive, data-driven QAPI program. The only document provided was a QAPI Plan Review form dated over two years prior, which was merely a sign-in sheet with staff signatures. Additionally, policy and procedure manuals were presented, but they did not pertain to the QAPI program. The Administrator claimed that monthly QAPI meetings were held and that there were two current performance improvement plans in place, but no documented evidence was available to support these claims. Furthermore, the Administrator mentioned an annual review of facility policies and procedures with the QAPI committee, yet no documentation was provided to verify this review. The facility's QAPI policy was also not provided during the survey.
Deficiency in Timely MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals within the required timeframes for five residents out of a sample of nine whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a survey of 34 residents. The residents affected included those with complex medical conditions such as congestive heart failure, dementia with behavioral disturbances, schizoaffective disorder, encephalitis, encephalomyelitis, hemiplegia/hemiparesis following a cerebral infarction, metabolic encephalopathy, and diffuse traumatic brain injury. The assessments in question were either incomplete or not finalized and electronically submitted, as required. The issue was primarily linked to the actions of an LPN who was responsible for initiating and transmitting the MDS assessments. The LPN had been assisting with these assessments for about 90 days and was unaware of the outstanding or overdue assessments until informed during the survey. Despite acknowledging the overdue assessments, the LPN stated she was doing her best to manage the workload. The Director of Nursing was responsible for reviewing and locking the assessments, but the deficiency persisted, indicating a lapse in the timely completion and submission of the required assessments.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals quarterly for four of nine sampled residents whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a review of resident records and an interview with staff. Specifically, the quarterly Minimum Data Set (QMDS) assessments for Residents #15, #14, #9, and #42 were not completed in a timely manner. Resident #15's QMDS initiated on 5/30/24 was still in progress, Resident #14's QMDS was also incomplete, Resident #9's most recent QMDS was still in progress, and Resident #42's QMDS was not completed. These assessments were initiated by Licensed Practical Nurse (LPN) J. During an interview, LPN J confirmed that she had been assisting with MDS assessments over the last 90 days and acknowledged the late submissions. She stated that once the assessments were done, the Director of Nursing reviewed and locked them, and then she transmitted them electronically. However, she was not aware of any outstanding or overdue assessments until informed of the findings. LPN J admitted to the late submissions and expressed that she was doing her best to help, indicating a lack of awareness and oversight in the timely completion of these assessments.
Failure to Notify Resident and LTCO of Emergency Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and her representative regarding an emergency hospital transfer, as well as failing to notify the Office of the State Long-Term Care Ombudsman (LTCO). The resident, who had a history of type 2 diabetes mellitus, schizoaffective disorder, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and seizure disorder, exhibited aggressive behavior on the day of the incident. She was pacing, yelling, and threatening other residents, which led to her being removed from the area. Despite these actions, she returned and continued to display aggressive behavior. A clinical psychologist completed a Certificate of Professional Initiating Involuntary Examination, noting the resident's refusal for voluntary examination and her potential to cause harm due to her mental illness. Consequently, the resident was admitted to a psychiatric ward with police assistance. However, the facility did not provide an AHCA Transfer/Discharge Notice to the resident or her representative, nor did they inform the LTCO in writing about the transfer. An interview with the Social Services Director confirmed the absence of written notice and notification to the LTCO, indicating a lapse in the facility's protocol for handling such transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the bed-hold policy and the duration for which the bed would be held during the resident's transfer to a hospital. This deficiency was identified during a review of resident records and staff interviews, specifically concerning a resident who was transferred to a psychiatric unit under an involuntary admission. The resident's medical record lacked evidence of any written notice about the bed-hold policy, which is a requirement. The resident involved had multiple diagnoses, including type 2 diabetes mellitus, schizoaffective disorder, dementia, and other mental health conditions. On the day of the incident, the resident exhibited aggressive behavior, threatening other residents and staff, which led to her being transported by police to a psychiatric unit. Despite these events, the facility did not provide the necessary written information about the bed-hold policy to the resident or her representative, as confirmed by the Social Services Director during an interview.
Failure to Refer Residents for PASRR Level II Screening
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses for a Pre-Admission Screening and Resident Review (PASRR) Level II screening, which is necessary to ensure appropriate care and services. This deficiency was identified for three residents out of a sample of 34. Resident #25 had diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder, but was not referred for a Level II screening upon admission or after new diagnoses. Similarly, Resident #40, admitted with major depressive disorder and later diagnosed with generalized anxiety disorder, was not referred for a Level II screening. Resident #47, diagnosed with generalized anxiety disorder, also lacked a Level II screening referral. The Social Services Director (SSD) acknowledged that there was no current system in place to review Level I screenings for new or existing diagnoses that would necessitate a Level II review. The SSD had previously been responsible for monitoring PASRRs and submitting Level II review requests, but this responsibility was shifted to nursing staff without a clear process in place. The facility's policy requires referrals for Level II reviews upon significant changes in residents' mental health status, but this was not adhered to, leading to the deficiency.
Failure to Supervise Resident's Nail Care
Penalty
Summary
The facility failed to identify and minimize the risk of accidents and provide adequate supervision to prevent accidental injury for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including unspecified dementia and schizoaffective disorder, was observed performing her own toenail care unsupervised, despite having a history of onychomycosis and associated pain. The resident's medical record lacked an assessment of her ability to safely perform her own nail care, and there was no facility policy or protocol regarding the use of nail clippers by residents. The resident was seen by a podiatrist who noted the risk of soft tissue damage due to her thickened, elongated toenails. Despite this, the resident was found trimming her toenails with a metal nail clipper without staff supervision. Interviews with staff revealed a lack of awareness regarding the resident's possession of nail clippers and the podiatrist's findings. The Director of Nursing and other staff members were unaware of any policy or protocol for assessing residents' safe use of sharp grooming implements. Staff interviews indicated that the resident was known to reject assistance with activities of daily living, and there was confusion among staff about who was responsible for toenail care. The resident's guardian was informed of the situation, and staff attempted to retrieve the nail clippers from the resident, who refused to relinquish them. The lack of communication and clear protocols contributed to the oversight in the resident's care, leading to the deficiency noted in the report.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions (EBP) for two residents. Resident #38, who was admitted with an indwelling urinary catheter and had a history of urinary tract infections, was observed multiple times with his catheter collection bag and tubing touching the floor, without any EBP signage on his room door. Interviews with staff revealed that while they had received some training on catheter care, there was a lack of consistent implementation of preventive measures, such as ensuring the catheter bag did not touch the floor. Similarly, Resident #22, who had an enteral feeding tube, was observed on several occasions without EBP signage on his room door. Staff interviews indicated confusion about how they were informed of residents requiring EBP, with reliance on electronic records and shift change reports rather than visible signage. The Infection Preventionist/Director of Nursing confirmed that signage should be present to alert staff and visitors of necessary precautions. The facility's infection prevention and control policy aimed to prevent the transmission of infections and manage nosocomial infections, but the observed deficiencies highlighted a gap in the implementation of these policies. The lack of EBP signage and improper catheter care practices for the sampled residents demonstrated a failure to adhere to the facility's stated procedures, potentially increasing the risk of infection transmission.
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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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Nursing homes near Deland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Palms Health And Rehabilitation Center Of Del | 0.5 mi | — | 0 | 0 |
| Parkside Health And Rehabilitation Center | 1 mi | — | 0 | 0 |
| Alliance Health And Rehabilitation Center | 1.4 mi | — | 0 | 0 |
| Athens Post Acute Llc | 1.8 mi | — | 14 | 0 |
| Villa Healthcare & Rehabilitation Center | 2.1 mi | — | 9 | 0 |
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