Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Ocala Health And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to accurately complete a resident's discharge assessment. A resident was discharged to a skilled nursing facility (SNF) out of state, but the Minimum Data Set (MDS) incorrectly recorded the discharge status as to a short-term general hospital. This error was confirmed by the LTC MDS Coordinator and another MDS Coordinator during interviews.
A resident initially admitted for respite care with diagnoses including dementia and mood disorder transitioned to long-term care without a completed PASRR. The facility failed to update the PASRR, as confirmed by staff interviews, despite policy requirements for Level I Determinations to be completed at admission.
A resident with hypotension received Midodrine HCL 5 mg despite having systolic blood pressure readings above the physician-ordered threshold. The facility's staff did not adhere to the specified parameters, as confirmed by interviews with the DON and an APRN. The facility's policy requires verification of medication parameters before administration, which was not followed.
A resident with a restriction against using straws due to choking risk was observed with drinks containing straws on their lunch tray. Despite clear orders and meal ticket instructions, staff failed to adhere to this precautionary measure. Interviews revealed a lack of awareness and adherence to the dietary restrictions, highlighting a deficiency in the facility's protocol implementation.
The facility failed to store food safely in three nourishment rooms, lacking thermometers in freezer compartments and having ice buildup. An undated pizza serving was found, and the Certified Dietary Manager confirmed these issues, acknowledging the need for defrosting and proper dating of food items.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and documentation. One resident's pain levels were inaccurately recorded, despite receiving pain medication, while another resident experienced confusion in insulin administration due to conflicting orders. The facility's documentation policy was not adhered to, resulting in discrepancies in care.
The facility failed to ensure proper use of PPE and adherence to infection control standards. A CNA did not wear required eye protection while caring for COVID-19 positive residents. An LPN used a blood pressure cuff on multiple residents without sanitizing it, and another LPN placed tissues on an unsanitized table. Additionally, a medication syringe was not cleaned after use. These actions were against the facility's policies, as confirmed by the DON.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that resident assessments were completed accurately, specifically regarding the discharge status of a resident. Resident #158 was discharged on April 2, 2024, to a skilled nursing facility (SNF) out of state, as per the physician's order and discharge instructions. However, the Minimum Data Set (MDS) for the resident incorrectly recorded the discharge status as being to a short-term general hospital. This error was identified during interviews with the Long Term Care MDS Coordinator and another MDS Coordinator, who both confirmed that the discharge status should have been coded as a transfer to a SNF, not a hospital.
Failure to Complete PASRR for Resident Transitioning to Long-Term Care
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) for a resident who was initially admitted for respite care and later transitioned to long-term care. The resident, who had diagnoses including unspecified dementia, depression, brief psychotic disorder, and mood disorder due to a known physiological condition, was admitted for a respite stay. The PASRR Evaluation Request was completed, but the medical chart lacked results for a Level I screen for serious mental illness and/or intellectual disability or related conditions. This oversight was identified during a review of the resident's medical chart and confirmed through interviews with facility staff. Staff C, a social worker, acknowledged that the resident's PASRR should have been updated when the decision was made to transition the resident from respite care to long-term care. The Director of Nursing also recognized that the PASRR was not correct and should have been addressed. The facility's policy requires that Level I Determinations be signed and dated by an RN at the time of admission, and the nursing facility is responsible for ensuring the completion and submission of Level I screenings. However, this process was not followed, leading to the deficiency.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to administer blood pressure medication according to the physician's orders for a resident diagnosed with hypotension. The physician's order specified that Midodrine HCL 5 mg should be held if the resident's systolic blood pressure exceeded 110. However, the Medication Administration Record (MAR) for June 2024 showed that the resident received the medication on multiple occasions despite having systolic blood pressure readings above the specified threshold, including readings of 120/80 and 122/80. Interviews with the Director of Nursing and an Advanced Practice Registered Nurse (APRN) revealed that the nursing staff did not adhere to the physician's parameters for holding the medication. The APRN acknowledged that the parameters were set conservatively due to the resident's age, but emphasized the importance of following them. The facility's policy on medication administration requires staff to verify the correct medication, dose, and parameters before administration, which was not followed in this case.
Failure to Adhere to Dietary Restrictions for Resident
Penalty
Summary
The facility failed to adhere to dietary restrictions for a resident, specifically regarding the use of straws, which were prohibited due to the resident's risk of choking and aspiration. During an observation, it was noted that the resident's lunch tray included drinks with straws, despite a clear order against their use. The resident's meal ticket and physician's order both specified 'no straws' due to the resident's facial weakness and poor dentition, which increased the risk of choking when using straws. The Speech Language Pathologist had recommended against the use of straws as a precautionary measure following a clinical evaluation and swallow study. Staff interviews revealed a lack of awareness and adherence to the dietary restrictions. A Registered Nurse admitted to not checking the meal ticket for straw restrictions and acknowledged the expectation for CNAs to read meal tickets. The Director of Nursing explained that therapy communications are supposed to be updated in the care plan by the unit manager, and serious orders are highlighted in the electronic medical record for CNAs. However, despite these protocols, the order for no straws was not followed, leading to the deficiency.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that foods were stored safely in three nourishment rooms, as observed during a tour conducted on June 24, 2024. In the East Hall nourishment room, there was no thermometer in the freezer compartment of the refrigerator, and an ice buildup was noted with a wire dangling from the ice. Similarly, in the North Hall nourishment room, the freezer compartment lacked a thermometer. In the South Hall nourishment room, there was no thermometer in both the freezer and cooling compartments of the refrigerator, and an ice buildup was observed in the freezer. Additionally, an undated individual pizza serving was found in the freezer. During an interview on the same day, the Certified Dietary Manager confirmed the absence of thermometers in the nourishment room refrigerators and acknowledged the need for defrosting in the East and South Hall freezer compartments. The manager also recognized that the individual pizza serving in the South Hall refrigerator was undated. The facility's policy on leftover food storage and use, last reviewed on January 18, 2024, requires leftover foods to be covered, labeled, and dated, and used within 72 hours. The policy on food storage temperature logs mandates that temperatures be monitored and recorded to prevent foodborne illnesses.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to deficiencies in medication administration and pain management documentation. For Resident #12, the facility did not accurately document pain levels as required by the physician's order. Despite receiving pain medication, the resident's pain level was consistently recorded as zero, contradicting progress notes indicating the resident experienced pain and required morphine. The Director of Nursing acknowledged that the nursing staff should have documented the highest level of pain at the end of each shift, as per the facility's pain management policy. For Resident #39, there was confusion and inconsistency in the administration of insulin due to conflicting physician orders. The resident had two active insulin orders, one for Novolog and another for Novolin R, both intended for blood glucose levels over 399 mg/dl. The MAR showed instances where insulin was administered without documenting the corresponding blood glucose readings, and there was no clear documentation to justify the deviation from the active orders. Interviews with the Director of Nursing and nursing staff revealed that the orders were confusing, and the staff relied on verbal communication and common knowledge rather than clear documentation. The facility's policy on charting and documentation emphasizes the importance of accurate and complete documentation of residents' care, including medication administration and responses. However, the lack of clear documentation and adherence to physician orders for both residents highlights a significant deficiency in maintaining accurate medical records. This failure to document appropriately could impact the residents' treatment and care, as evidenced by the discrepancies in pain management and insulin administration.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing direct care to residents on transmission-based precautions. Specifically, a Certified Nursing Assistant (CNA) was observed not wearing eye protection while interacting with two residents who were positive for COVID-19. Despite the facility's policy requiring the use of gowns, face masks, eye protection, and gloves for COVID-19 positive rooms, the CNA admitted to not wearing a face shield or goggles, acknowledging the oversight during an interview. The Director of Nursing confirmed that staff should adhere to these PPE requirements. Additionally, the facility did not adhere to infection control standards regarding the cleaning of multi-use medical equipment. An LPN was observed using a blood pressure cuff on multiple residents without sanitizing it between uses. The LPN acknowledged the lapse, citing a lack of sanitizing wipes in the medication cart. Furthermore, another LPN placed tissues on an unsanitized bedside table and used them for a resident, contrary to the facility's policy of sanitizing surfaces or using barriers. The facility also failed to clean medication syringes after use, as observed with an LPN administering medication via a gastric tube. The LPN did not clean the syringe after administration, intending to do so later, which was against the facility's policy. The Director of Nursing confirmed that staff should clean reusable medical equipment between uses and sanitize surfaces before placing items on them. These deficiencies highlight lapses in following established infection control protocols, potentially increasing the risk of infection spread.
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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 Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Arbor Springs | 0.2 mi | — | 7 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 0.7 mi | — | 0 | 0 |
| Avante At Ocala, Inc | 0.9 mi | — | 1 | 0 |
| Palm Garden Of Ocala | 2.9 mi | — | 1 | 0 |
| Life Care Center Of Ocala | 3.1 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.