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 Ocala Oaks Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) to two residents within the mandated two-day timeframe before the end of their Medicare Part A coverage. In one case, the form was signed only one day prior to coverage ending, and in another, it was signed after coverage had ended. Staff interviews confirmed the forms were not delivered as required by policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to follow physician orders for two residents: one did not receive wound care as prescribed, with improper dressing application and lack of documentation, while another did not receive IV antibiotics at the ordered every-8-hour intervals, instead receiving them on a TID schedule. The DON and staff confirmed the deviations from prescribed care.
Surveyors found that two residents were administered oxygen at rates higher than ordered by their physicians, and a third resident's nebulizer mask was not stored in a plastic bag when not in use, contrary to facility policy. The DON and unit manager confirmed that these practices did not follow established procedures.
Surveyors found that kitchen equipment, including can openers and stove drawers, had significant buildups of dirt and food debris, and that cleaning schedules were not followed as required by facility policy. The Food Service Director confirmed the lack of completed cleaning checklists and acknowledged that cleaning assignments were not being completed.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required. Surveyors found no documentation or description of how these quality assurance activities are implemented.
Multiple live insects, including cockroaches, were observed in the kitchen area during a tour with the ADM and FSD. Documentation from the pest control company confirmed repeated pest activity in various kitchen locations over several months. Despite a policy requiring routine inspections and reporting, pests continued to be present, demonstrating a failure to maintain an effective pest control program.
The facility failed to provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two residents. The Social Services Director confirmed that the signed copies for the residents were missing and were only signed months later, outside the required timeframe.
A facility failed to implement physician orders following pharmacist recommendations for a resident with multiple diagnoses. Despite the physician accepting the pharmacist's recommendations to discontinue Cyclobenzaprine and Prednisone, the orders were not processed, and the resident continued to receive the medications. The DON admitted that consultation reports were not reviewed, and the facility's policy was not followed.
The facility failed to ensure complete and accurate medical records for several residents, particularly in insulin administration and PICC dressing changes. Staff did not document missed insulin doses or notify physicians, and there were inconsistencies in following protocols for medication administration and documentation.
The facility failed to transmit resident assessment data within 14 days after completion for two residents. One resident, admitted with multiple diagnoses, was discharged home, and their MDS Discharge Return Not Anticipated Assessment was not submitted to CMS. Another resident, also admitted with multiple diagnoses, was discharged home, and their MDS Discharge Return Not Anticipated Assessment was not submitted to CMS. The MDS Coordinator confirmed the failure, and the Administrator acknowledged the absence of a policy on submitting MDS Assessments.
A resident with cerebral infarction and hemiplegia did not receive the required restorative services to maintain or improve range of motion. Despite a care plan indicating the need for an Active Assistive Range of Motion Program, there were significant gaps in the documentation and provision of these services, as confirmed by the Director of Clinical Services and the Director of Rehabilitation Services.
A resident with COPD and other conditions was observed receiving oxygen at 3.5 L/min instead of the prescribed 2 L/min. Staff confirmed the discrepancy, and the facility's policy on oxygen administration was not followed.
The facility failed to ensure the posted nurse staffing data included the required information. The nursing staffing data did not contain the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This deficiency was confirmed by the Administrator, DON, and Staff Development Coordinator, who stated that the night shift charge nurse is responsible for filling out and posting the data before the end of her shift, using the midnight census total.
The facility failed to ensure staff used appropriate PPE during direct care for three residents under transmission-based precautions and did not follow infection control practices for another resident during dining. An LPN did not wear a gown while discontinuing an IV catheter, a CNA provided direct care without a gown, and another CNA was unaware of a resident's need for enhanced barrier precautions. Additionally, a resident had a urinal with drops of urine on his meal table, and a CNA placed the food tray next to it.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents within the required two-day timeframe prior to the end of their Medicare Part A coverage. For one resident, the NOMNC form indicated the last covered day as 6/17/2025, but the form was signed on 6/16/2025, only one day prior. For the second resident, the last covered day was 3/4/2025, but the form was signed by the resident's representative on 3/5/2025, after the coverage had already ended. The facility was unable to provide documentation of the email sent to the representative for signature. Interviews with the Social Services Director (SSD) and the Administrator confirmed that the NOMNC forms were not delivered 48 hours before the last covered day as required by policy. The SSD acknowledged responsibility for reviewing, obtaining signatures, and filing the NOMNC forms, and confirmed the forms for both residents were not provided within the mandated timeframe. Review of facility policy reiterated the requirement to deliver the NOMNC at least two calendar days before Medicare-covered services end.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Wound Care and IV Antibiotic Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding wound care and intravenous antibiotic administration. For one resident with a wound on the lower left leg, observation revealed that the dressing was not dated or initialed, and part of it was peeling off. The resident reported not having received wound care for four days. Review of the physician's order specified a detailed wound care regimen, including cleansing, application of collagen powder and calcium alginate, covering with an ABD pad, wrapping with kerlix and an ACE bandage, and offering pain medication prior to treatment, to be performed every shift. The Wound Care Nurse confirmed the dressing was incorrect and not applied as ordered, and the DON stated that dressings should be applied per order and dated. For another resident readmitted with multiple serious diagnoses, including sepsis and malignancies, the facility failed to administer the intravenous antibiotic Meropenem as prescribed. The physician ordered Meropenem 1 gram IV every 8 hours for four doses, but the medication was instead scheduled and administered according to the facility's standard three times daily (TID) schedule, not at the prescribed intervals. The DON acknowledged that the every-8-hour schedule was not discussed with the physician and the medication was entered into the system as TID. Both the pharmacy consultant and the physician confirmed that the medication should have been administered every 8 hours as ordered.
Failure to Follow Physician Orders for Oxygen Therapy and Proper Storage of Nebulizer Equipment
Penalty
Summary
Surveyors observed that two residents were not receiving oxygen therapy in accordance with their physician orders. One resident was administered oxygen at 3 liters per minute (lpm) via nasal cannula, while the physician order specified 2 lpm continuously. This resident had a medical history including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, non-ST elevation myocardial infarction, and dependence on supplemental oxygen. Another resident was observed receiving oxygen at 4 lpm via nasal cannula, despite a physician order for 2 lpm continuously. This resident's diagnoses included dependence on supplemental oxygen and shortness of breath. In both cases, the Director of Nursing confirmed that physician orders should be followed for oxygen administration, and facility policy required checking the physician’s order and setting the correct flow rate. Additionally, a third resident’s nebulizer mask was found resting on top of the nebulizer machine and not stored in a plastic storage bag when not in use, as required by facility policy. The resident had a physician order for Ipratropium-Albuterol inhalation solution to be administered as needed for shortness of breath or wheezing, with the last administration documented the previous day. Both the unit manager and the Director of Nursing confirmed that nebulizer masks should be stored in a plastic bag when not in use, in accordance with the facility’s aerosol therapy policy.
Failure to Maintain Cleanliness and Follow Cleaning Schedules in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen equipment in a safe and clean condition and did not follow established cleaning schedules for the kitchen and food service equipment. During multiple kitchen inspections, significant buildups of dirt, food debris, and discoloration were found on equipment such as table-mounted and counter can openers, the stove's catch drawer, prep tables, and stainless-steel counters. The Food Service Director (FSD) confirmed the presence of these buildups and acknowledged that the stove catch-drawer and other equipment should have been cleaned. A review of facility documentation revealed that the cleaning schedule was not being followed, as no completed checklists were available for review. The FSD confirmed that cleaning assignments were not being completed as required. The facility's own policy required daily cleaning duties to be listed, cleaning assignments to be posted, and schedules to be initialed and dated upon completion, but these procedures were not adhered to, resulting in unsanitary kitchen conditions.
Lack of Documented QAPI/QAA Process
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or a described process outlining how QAPI and QAA activities are to be carried out within the facility.
Failure to Maintain Effective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple live insect sightings in the kitchen area during a tour with the Administrator and Food Service Director. Observations included live insects around the blade of a counter-mounted can opener, on a utility cart, on the coffee counter, and on the ceiling strip of the exterior back wall. Both the Administrator and Food Service Director confirmed these pest sightings in the dietary department/kitchen, and the Food Service Director reported that roaches had been seen on numerous occasions in the past few weeks, with notifications documented in the pest log. Review of pest control documentation from the contracted pest control company revealed that cockroaches were noted during services in both May and July, with findings in the kitchen above the drop ceiling, in the steam table, behind ovens, and in the dish area. The facility's pest control policy requires routine inspections, documentation of sightings, and communication with the maintenance supervisor, as well as staff training and regular cleaning measures. Despite these procedures, the presence of pests persisted, indicating a failure to ensure the effectiveness of the pest control program.
Failure to Provide Timely SNF ABN Forms
Penalty
Summary
The facility failed to ensure that residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) within the required time frame for two residents. For Resident #18, the Medicare Part A Skilled Services Episode started on 11/27/2023, and the last covered day was 1/4/2024. However, the signed SNF ABN form could not be located for the January 2024 discharge date. The resident eventually signed the form on 5/15/2024, which was not within the acceptable period. Similarly, for Resident #25, the Medicare Part A Skilled Services Episode started on 3/20/2024, and the last covered day was 4/23/2024. The signed SNF ABN form for the April 2024 discharge date was also missing and was only signed on 5/15/2024 by the resident's representative, which was again outside the required timeframe. During an interview, the Social Services Director, who started on 1/22/2024, confirmed that they were responsible for reviewing the SNF ABN and Notice of Medicare Non-Coverage (NOMNC) forms with residents and their representatives, obtaining signatures, and filing the forms appropriately. The director admitted that the signed copies for the two residents could not be located and were only signed on 5/15/2024, which was not within the acceptable period. The facility's policy, last reviewed in 8/2023, mandates that Medicare denial letters must be used to notify residents of non-coverage at the time of admission or for termination of benefits following a covered Part A stay. The policy also specifies that the SNF ABN form should be provided to residents before the termination of current services under Medicare or before receiving specific items/services that Medicare probably will not cover.
Failure to Implement Physician Orders Following Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physician orders following the pharmacist's recommendations were implemented for a resident reviewed for unnecessary medications. The resident, who had multiple diagnoses including heart failure, dementia, and chronic pain, was prescribed Cyclobenzaprine and Prednisone. The pharmacist recommended discontinuing these medications due to their potential adverse effects, and the physician accepted these recommendations. However, the orders to discontinue the medications were not processed, and the resident continued to receive Prednisone daily and Cyclobenzaprine on specific dates from February to May 2024. The Director of Nursing (DON) stated that the responsibility for reviewing the consultation reports was transferred to the Assistant Director of Nursing (ADON) in February 2024. The DON admitted that the consultation reports for March and April 2024 were not reviewed, and the changes recommended by the pharmacist were not implemented. The facility's policy requires that the attending physician document any action taken in response to the pharmacist's recommendations and that the Medical Director be alerted if recommendations are not addressed in a timely manner. This policy was not followed, leading to the deficiency.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for several residents, specifically in the administration of insulin and PICC dressing changes. For Resident #39, the Medication Administration Record (MAR) showed multiple instances where insulin was not administered as required, and there was no documentation in the progress notes regarding the missed doses or notification of the physician. Similarly, Resident #62's MAR indicated several instances of missed insulin administration without corresponding documentation or physician notification. Resident #46's MAR also showed discrepancies in insulin administration, with staff failing to document communication with the physician when insulin was held due to low blood sugar levels. Additionally, the facility failed to follow physician orders for PICC dressing changes for Resident #107. The resident's MAR indicated daily dressing changes, contrary to the physician's order for a one-time change 24 hours post-insertion and then every seven days. Interviews with staff, including RNs, LPNs, the ADON, and the DON, revealed inconsistencies in following protocols for insulin administration and documentation. Staff admitted to not documenting communications with physicians and not adhering to the facility's policy for medication administration. The Medical Director and physicians confirmed that while they were notified of insulin holds, the nursing staff failed to document these communications properly. The DON acknowledged that all communication between nurses and providers should be documented, and the lack of documentation indicated non-compliance with the facility's policies. The ADON and other staff members also highlighted the importance of documenting all actions and communications related to medication administration to ensure resident safety and compliance with professional standards.
Failure to Transmit Resident Assessment Data
Penalty
Summary
The facility failed to transmit resident assessment data within 14 days after completion of assessment for two residents. Resident #99 was admitted with multiple diagnoses including arthritis, postprocedural septic shock, type 2 diabetes mellitus, hypertension, atrial fibrillation, chronic kidney disease, and ileostomy status, and was discharged home on 12/15/2023. The MDS Discharge Return Not Anticipated Assessment for Resident #99, completed on 12/21/2023, was not submitted to CMS. Similarly, Resident #71, admitted with diagnoses including anemia, congestive heart failure, atrial fibrillation, and acute cholecystitis, was discharged home on 1/5/2024. The MDS Discharge Return Not Anticipated Assessment for Resident #71, completed on 1/8/2024, was also not submitted to CMS. The MDS Coordinator confirmed the failure to submit these assessments, and the Administrator acknowledged the absence of a policy on submitting MDS Assessments, stating that they follow the RAI guidelines.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate restorative services to maintain or improve range of motion. Resident #86, who had diagnoses including cerebral infarction, hemiplegia, and reduced mobility, was observed lying in bed with her left arm in a bent position against her chest. The resident expressed a desire for therapy, stating she had not received it in months and wanted to go home. Interviews with staff revealed that while the resident was receiving occupational therapy until early February 2024, the services were supposed to transition to a Restorative Nursing Program (RNP) afterward. However, there were significant gaps in the documentation and provision of these restorative services as evidenced by missing entries in the task tracking sheets for April and May 2024. The Director of Clinical Services acknowledged the gaps in documentation and confirmed that the resident had not received the restorative services as required. The care plan for the resident indicated a need for an Active Assistive Range of Motion Program for the left upper extremity, but the task tracking sheets showed multiple dates with no documented entries, indicating a failure to provide the necessary services. The Director of Rehabilitation Services stated that the frequency of services should have been determined by the therapist and included in the Restorative Nursing Services Evaluation, but this was not consistently done, leading to the deficiency in care for Resident #86.
Failure to Follow Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident #51 received respiratory care services as prescribed. Observations on multiple occasions revealed that the resident's oxygen concentrator was set to 3.5 liters per minute (L/min), despite the physician's order specifying 2 L/min as needed for shortness of breath. The resident was observed with the nasal cannula intact and the oxygen concentrator running at the incorrect setting on three separate occasions over two days. The resident's medical history includes Chronic Obstructive Pulmonary Disease (COPD), chronic peripheral venous insufficiency, shortness of breath, and dementia. Interviews with staff confirmed the discrepancy between the prescribed oxygen flow rate and the actual setting. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both acknowledged that the oxygen concentrator was not set according to the physician's order. The facility's policy on oxygen administration, which includes checking the physician's orders and monitoring the resident's response to oxygen therapy, was not followed. This failure to adhere to prescribed respiratory care protocols led to the deficiency noted in the report.
Failure to Post Complete Nurse Staffing Data
Penalty
Summary
The facility failed to ensure the posted nurse staffing data included the required information. During an observation on 5/13/2024 at 9:00 AM, the nursing staffing data for that day did not contain the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This deficiency was confirmed by the Administrator on 5/15/2024 at 8:00 AM, who stated that the night shift is responsible for the federal posting for staffing, and the Staff Coordinator would review the posting for accuracy upon arrival. The Director of Nursing (DON) and the Staff Development Coordinator also confirmed that the night shift charge nurse is responsible for filling out and posting the nursing staffing data before the end of her shift at 7 AM, using the midnight census total. The facility's policy and procedures titled Nursing Scheduling/Staffing/Posting, last revised in 8/2023, require that the center post specific nurse staffing information daily, including the center name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census. The policy also mandates that this data be posted at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors. The failure to include the required information in the posted nurse staffing data indicates non-compliance with the facility's own policies and federal requirements.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure staff used appropriate PPE during direct care for three residents under transmission-based precautions and did not follow infection control practices for another resident during dining. Specifically, a Licensed Practical Nurse (LPN) did not wear a gown while discontinuing an intravenous catheter for a resident with enhanced barrier precautions due to a wound. Another Certified Nursing Assistant (CNA) entered a resident's room without a gown and provided direct care, despite the resident being on enhanced barrier precautions for a wound. Additionally, a CNA was unaware of a resident's need for enhanced barrier precautions due to a dialysis port, and no signage or PPE was available outside the resident's room. The Infection Preventionist confirmed the need for enhanced barrier precautions for residents with indwelling devices to prevent MDROs, but the resident was not listed on the infection control line listing, and no orders were in place for enhanced barrier precautions for this resident. Furthermore, during a dining observation, a resident had a urinal with drops of urine on his meal table, and a CNA placed the resident's food tray next to the urinal. The resident mentioned that the urinal had fallen on the floor, and he had placed it on the table. A Licensed Practical Nurse (LPN) later stated that the urinal should not be on a table next to a food tray and would have taken steps to clean the table and provide a new tray if observed. These actions and inactions led to deficiencies in infection prevention and control practices within the facility.
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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) |
|---|---|---|---|---|
| The Lodge Healthcare And Rehabilitation Center | 3.6 mi | — | 0 | 0 |
| Aviata At Arbor Springs | 3.6 mi | — | 7 | 0 |
| Ocala Health And Rehabilitation Center | 3.6 mi | — | 10 | 0 |
| Avante At Ocala, Inc | 4.1 mi | — | 1 | 0 |
| Palm Garden Of Ocala | 6.3 mi | — | 1 | 0 |
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