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 Florence Health Services during CMS and state inspections, most recent first.
The facility failed to maintain toilets in a clean and homelike condition when multiple shared-bathroom toilets contained rusty metal strips at the openings or under elevated seats, which several residents reported as bothersome. Residents stated they had informed CNAs, housekeeping, and maintenance about the rust, but these concerns were not reflected in maintenance request logs. A housekeeper acknowledged seeing the rust and hearing resident complaints, and an account manager admitted being aware of the condition but did not report it. An LPN, the DON, and the executive director all confirmed upon observation or interview that the rusty strips were inappropriate and not consistent with a safe, homelike environment.
A resident with vascular dementia, urinary tract issues, and an indwelling catheter experienced a change in condition, including confusion and milky, yellow urine. The care plan required staff to report and document such changes and possible UTI signs. Nursing notes recorded the abnormal urine and later an SBAR entry noted abnormal BP, increased confusion, and new orders for urinalysis/culture and increased fluids, with subsequent transfer to urgent care and hospital admission. However, the DON, who reported contacting a urology department and receiving instructions to send the resident to urgent care, did not document these provider notifications or related details in the medical record, resulting in incomplete documentation of the change in condition and provider communication.
Three residents experienced abuse due to the facility's failure to investigate and implement interventions after an initial altercation involving verbal and physical aggression. The care plan for the aggressive resident was not updated, and staff were unaware of the incident, leading to a subsequent physical assault on another resident. The residents involved had moderate cognitive impairment and other significant medical conditions.
A resident-to-resident altercation involving verbal and physical aggression was not reported to the State Agency as required by facility policy. Both residents involved had moderate cognitive impairment and significant medical histories. The DON was unaware of the full extent of the incident and confirmed that the required report was not made.
Two residents with moderate cognitive impairment were involved in a verbal and physical altercation, including yelling and the use of mobility aids in a confrontation. Despite facility policy requiring immediate investigation of abuse allegations, no thorough investigation was conducted, and the DON was unaware of the incident's extent.
A resident with a history of trauma and multiple chronic conditions did not have a care plan that included specific trauma-related diagnoses, triggers, or individualized interventions, despite assessments identifying these needs. Staff interviews revealed that team members were unaware of the resident's trauma history or how to respond to trauma-related events, and the care plan contained only generic statements. This lack of individualized planning resulted in staff being unprepared to address the resident's trauma needs, especially after a physical assault by another resident.
A resident with diabetes and multiple comorbidities was admitted with hospital discharge orders for scheduled and sliding scale insulin, as well as recommendations for close blood glucose monitoring. The facility failed to transcribe the sliding scale insulin order and did not implement frequent blood sugar checks, resulting in only once-daily monitoring and omission of the sliding scale regimen. Staff interviews revealed confusion about order transcription and monitoring frequency, and the pharmacy did not identify the missing order.
A medication cart containing drugs and biologicals was left unlocked and unattended by an LPN during medication administration, with multiple residents passing by the exposed drawers. Facility policy requires medication carts to be locked when not attended by authorized staff, and both the LPN and DON confirmed this standard was not followed.
A resident with intact cognition reported to staff that a CNA got in their face and refused to provide requested care, which the resident described as abuse. Although the incident was reported internally and to the State Agency, the facility did not notify local law enforcement as required by policy and federal regulations. The NHA was aware of the reporting requirements but did not report the allegation to law enforcement, relying instead on a later conversation with the resident.
A resident with severe cognitive impairment was reported by family to have missing cash from their wallet. The facility investigated by interviewing the resident and family, and searching the resident's room, but could not determine what happened to the money. Despite policy requirements, no staff education or preventative action was taken following the allegation of misappropriation.
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete documentation and delayed reporting of a COVID-19 outbreak. The Infection Preventionist's dual role as a floor nurse hindered proper management, leading to inconsistent symptom tracking for residents. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with wounds or MDROs, further highlighting deficiencies in infection control practices.
The facility failed to ensure the Infection Preventionist (IP) dedicated sufficient part-time hours to manage the infection prevention and control program. An LPN, also working full-time as a floor nurse, was only able to allocate about 2 hours per week to IP duties, leading to an incomplete infection prevention program, as observed by surveyors.
The facility failed to store and prepare food in a sanitary manner, affecting most residents. Food items lacked proper labeling with open and use-by dates, and microwave heating procedures were not followed, as food was not covered or allowed to stand for the required time. Additionally, the temperature of sanitizing solutions was not tested, only the PPMs, contrary to instructions. The Dietary Manager and Registered Dietician acknowledged these oversights.
A resident was unnecessarily administered antibiotics due to the facility's failure to implement its antibiotic stewardship program. The resident was prescribed Bactrim DS for a UTI that did not meet infection criteria, and the culture showed resistance to the antibiotic. The physician was not informed of the culture results, leading to the completion of an ineffective seven-day course. The Infection Preventionist acknowledged the oversight, highlighting a lapse in communication and adherence to the facility's policy.
The facility failed to document the offer or administration of the 2024-2025 COVID-19 vaccine for three residents, as required by their policy. Despite previous declination forms, there was no record of the most recent vaccine offer or refusal, confirmed by the Infection Preventionist.
A resident with a history of stroke and other conditions was hospitalized with a head injury after a fall from a Hoyer lift. During a later hospitalization, hospital staff found a vaginal mucosa tear, leg bruises, and spinal fractures, which the facility failed to report to the State Agency. Interviews revealed staff were unsure about reporting requirements, and no investigation was conducted into the injuries.
A resident in a long-term care facility was hospitalized with a head injury after a fall and later found to have a vaginal mucosa tear, bruises, and compression fractures. The facility failed to investigate these injuries, despite being notified by hospital staff. Interviews with facility staff revealed a lack of awareness and action regarding the new injuries, and no investigation was conducted to determine their cause.
A facility failed to provide proper notification to a resident, their POA, and the Ombudsman regarding hospital transfers. The resident, with a history of stroke and other conditions, was transferred twice without receiving written notices. The DON signed notices on behalf of the resident and POA, but there was no documentation of mailing. Staff were unaware of notification requirements for ED transfers, leading to the deficiency.
A facility failed to provide a resident and their POA with written information about the bed hold policy during hospital transfers. The resident, who had a history of stroke and other medical conditions, was transferred twice without receiving the required notice. Staff were unfamiliar with the policy, and documentation was incomplete, leading to a deficiency in procedural compliance.
A resident's meal preference for French toast was not honored during lunch service, despite multiple requests from staff. The resident, who consistently preferred French toast due to feeling ill with other foods, left the dining area without eating. The facility's failure to update the meal ticket and lack of preparation knowledge contributed to the deficiency.
The facility failed to prepare pureed meals according to standardized recipes, using water instead of broth or gravy, which compromised the nutritional value for two residents. Additionally, one resident did not receive all items listed on their meal ticket, as a pureed cranberry muffin was omitted. These actions were contrary to the facility's dietary policies and procedures.
The facility did not ensure pneumococcal vaccinations were reviewed, offered, or administered to two residents as per CDC guidelines. The medical records lacked declination forms and documentation of vaccine discussions. The Infection Preventionist admitted to not having a system for pneumococcal vaccines, focusing more on COVID-19 and influenza vaccines.
A resident with a history of malignant neoplasm and dysphagia experienced low blood pressure, vomiting, and diarrhea. The facility failed to promptly notify the physician of these changes, despite policy requirements. The resident initially refused hospital transfer, and the physician was only contacted after the resident's daughter intervened. The physician was not informed of the vomiting and diarrhea until later in the day.
A resident undergoing chemotherapy for esophageal cancer did not have a comprehensive care plan addressing increased risks for infection, dehydration, or abnormal lab values. Despite facility policy requiring such plans, the care plan lacked necessary interventions and monitoring guidelines. The DON acknowledged the expectation for a care plan, highlighting a lapse in adherence to care planning processes.
A resident undergoing chemotherapy for esophageal cancer experienced low blood pressure, vomiting, and diarrhea, but the facility failed to conduct a comprehensive assessment of his condition. Despite the facility's policy requiring frequent monitoring, no formal hydration assessment was performed. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis.
Failure to Maintain Clean and Homelike Toilet Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ toilets in a clean, safe, and homelike condition as required by its Safe and Homelike Environment Policy. Surveyors observed rusty metal strips at the openings of toilets in the shared bathrooms of four residents. One resident’s toilet had a rusty metal strip at the opening, and the resident reported that it bothered them and that they had informed a CNA and a housekeeper. Another resident was seen exiting a bathroom where the toilet also had a rusty metal strip; this resident stated they did not like the strip and had told staff about it previously. A third resident’s toilet had an elevated seat resting on a rusty metal strip, and this resident stated the strip bothered them and that they had reported it to maintenance a long time ago. A fourth resident’s shared bathroom toilet also contained a rusty metal strip at the opening. Staff interviews and record review showed that these concerns were not acted upon or documented through the facility’s maintenance systems. An LPN initially stated she had not seen rusty metal strips on toilets but, upon observation, acknowledged the condition was not acceptable. A housekeeper reported having noticed a rusty metal strip and said he had placed it on a maintenance clipboard at one time and confirmed residents had complained, noting the rust resembled feces. However, maintenance request logs from several months contained no entries about rusty metal toilet strips. The account manager supervising housekeeping admitted awareness of the rusty strips and acknowledged they were not homelike but had not reported them. The DON stated the strips were attached to toilet handrails and that housekeeping should have reported resident complaints or entered them into the computerized maintenance program, confirming they were not on the maintenance log and that toilets should not contain rusty metal strips. The executive director stated the strips had been present for a long time, were not appropriate, and that she had not been notified of resident complaints.
Failure to Document Provider Communication During Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete medical records and document provider communication during a resident’s change in condition, as required by its Change in Condition of the Resident policy. That policy specifies that documentation must include a description of the change, assessment findings, emergency care provided, provider notification with date, time, conveyed information, and orders received, responsible party notification, and names and titles of employees involved. The resident at issue had vascular dementia, a history of UTI, obstructive and reflux uropathy, benign prostatic hypertrophy with lower urinary tract symptoms, and an indwelling urinary catheter. The resident’s care plan directed staff to report changes in urine amount, color, or odor, and to report signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, or pain/burning to the physician. On the date in question, a nursing progress note recorded that the resident was in the hall with a walker, believed it was time for breakfast, was reoriented and assisted back to bed, and that the indwelling catheter was draining milky, yellow urine. Later that day, an eINTERACT SBAR note documented abnormal blood pressure and increased confusion, and that the provider ordered a urinalysis/culture and increased oral fluids. A physician discharge summary indicated the medical director and family were aware of orders to send the resident to urgent care, from which the resident was admitted to the hospital. The DON reported she was notified of the resident’s condition early that morning, called the urology department to seek an appointment, and later received instructions to send the resident to urgent care, but acknowledged she did not document in a progress note that she notified the physician or the urology department, despite the policy requirement. The ED also stated the resident’s change in condition should have been documented earlier in the day, demonstrating incomplete documentation of the change in condition and related provider communication.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident altercations, for three of five sampled residents. On 9/11/25, an altercation occurred between two residents involving verbal and physical aggression, including yelling, swearing, threats, and physical contact with mobility devices. The care plan for the resident identified as the initial aggressor did not include goals, triggers, or interventions related to aggressive behavior, and the incident was neither investigated nor reported to the State Agency as required by facility policy. Following this, on 9/13/25, the same resident entered another resident's room and physically assaulted them by slapping them multiple times. This second incident was investigated and reported, but the lack of intervention after the first altercation was noted as a missed opportunity to prevent further abuse. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that they were unaware of the initial incident and acknowledged that it should have been investigated and addressed per policy. The residents involved had significant medical and cognitive conditions, including dementia with behavioral disturbance, cerebral infarction, and other chronic illnesses. Both the Unit Manager and Director of Nursing confirmed that the care plan for the aggressive resident should have been updated immediately after the first incident, and that the failure to do so left other residents unprotected from further aggression.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Agency as required by its own policy and federal regulations. An altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, which involved verbal and physical aggression, including yelling, swearing, threatening, and pushing mobility devices against each other. The incident was documented in the medical record, and one resident was subsequently moved out of the shared room. However, the Director of Nursing was not aware of the full extent of the altercation and confirmed that the incident was not reported to the State Agency. The facility's policy mandates that all allegations of abuse, neglect, or exploitation be reported to the State Agency and other authorities within specified timeframes, depending on the severity of the incident. Despite this, the altercation between the two residents was not reported, and there was no evidence of a report being made when requested by the surveyor. Interviews with both residents confirmed the occurrence of the altercation, and the Director of Nursing acknowledged the reporting failure during the survey.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
A resident-to-resident altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, including dementia and cerebral infarction. The incident involved verbal and physical aggression, with yelling, swearing, and the use of mobility aids in a physical confrontation. Documentation in the medical record described the altercation, and interviews with both residents confirmed the occurrence, with one resident recalling the argument and physical contact, and the other unable to recall the event. Despite the facility's policy requiring immediate investigation of any alleged abuse, neglect, or exploitation, there was no evidence that a thorough investigation was conducted following the altercation. The Director of Nursing was unaware of the full extent of the incident and confirmed that no investigation had been initiated. This failure to investigate was in direct violation of the facility's own policies and procedures regarding the handling of abuse allegations.
Failure to Develop and Implement Individualized Trauma-Informed Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement an individualized, comprehensive, resident-centered care plan for a resident identified as having trauma. The resident had a history of chronic medical conditions, including COPD, alcoholic polyneuropathy, alcoholic cirrhosis with ascites, type 2 diabetes, and respiratory failure with hypoxia. Despite quarterly assessments indicating the resident experienced trauma related to life-threatening illness and exposure to combat and captivity, the resident's diagnoses list did not include a trauma-related diagnosis, and the care plan lacked resident-specific trauma interventions. The care plan in place contained general statements and non-specific interventions, such as determining triggers and de-escalation preferences, providing a safe environment, and referring to psychology as indicated. However, it did not specify the resident's actual trauma triggers or preferred interventions, even though the resident had communicated these during assessments. Staff interviews revealed that multiple team members, including RNs, CNAs, the DON, the Unit Manager, the MDS Coordinator, and the Social Services Coordinator, were unaware of the resident's trauma history, triggers, or specific interventions. Staff consistently stated that care plans should be personalized and include specific triggers and interventions to guide care, but this was not done for the resident in question. An incident occurred in which the resident was physically assaulted by another resident, resulting in significant distress and ongoing upset for the affected resident. Staff were not aware of how to respond to the resident's trauma or triggers following the incident, as the care plan did not provide the necessary individualized information. The Social Services Coordinator, who had signed off on the trauma assessments, acknowledged that the care plan should have been edited to include the resident's specific trauma and triggers but had not done so. This lack of individualized planning and communication led to staff being unprepared to meet the resident's trauma-related needs.
Failure to Transcribe and Implement Sliding Scale Insulin Order for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure the accurate administration of medication for a resident with multiple complex diagnoses, including type 2 diabetes, coronary artery disease, hypertension, COPD, diabetic foot ulcers with gangrene, cellulitis, and sepsis status post below-knee amputation. Upon admission from the hospital, the resident's discharge summary included orders for scheduled insulin (Lantus and lispro) and a sliding scale insulin regimen, along with a recommendation to monitor blood sugars closely. However, the sliding scale insulin order and the recommendation for frequent blood glucose monitoring were not transcribed into the resident's Medication Administration Record (MAR), and only once-daily blood glucose checks were ordered and performed. Staff interviews and record reviews revealed that the facility's process for transcribing hospital discharge orders was not followed thoroughly. The Director of Nursing (DON) and nursing staff indicated that orders are transcribed from the discharge summary and reviewed by the provider and pharmacy, but the sliding scale insulin order was omitted. Nursing staff were unaware that the sliding scale order was missing, and there was confusion regarding the frequency of blood glucose monitoring. The facility's policies required verification and clarification of transfer orders, but this was not done for the sliding scale insulin order. Further, the pharmacy did not identify the missing sliding scale order during their review, as they only check for discrepancies if a medication appears to be off. The DON acknowledged that the sliding scale should have been clarified and included in the orders, and that there was no process in place for a second nurse to double-check the transcription of admission orders. As a result, the resident did not receive blood glucose monitoring or insulin administration according to the hospital discharge instructions.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a medication cart was left unlocked and unattended by an LPN during medication administration on multiple occasions. The medication cart, which contained drugs and biologicals, was observed by a surveyor to be left open and unattended in the 200 wing and outside the dining room, with the drawers facing the hallway and exposed during the medication pass. Multiple residents were observed walking or wheeling past the unattended cart, increasing the risk of unauthorized access. The facility's policy, dated January 2023, requires that medication carts remain locked when not in use or when not attended by authorized personnel. During interviews, the LPN acknowledged that the cart should not have been left unlocked and stated that it was usually locked but was forgotten on these occasions. The DON also confirmed that medication carts are required to be locked when unattended.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an allegation of abuse made by a resident. A resident with intact cognition and responsible for their own healthcare decisions reported to staff that a Certified Nursing Assistant (CNA) got in their face and refused to wash them when requested, which the resident identified as abuse. The incident was reported internally and to the State Agency, and the CNA was suspended pending investigation. However, the facility did not notify local law enforcement of the allegation as required by their policy and federal regulations. Interviews and record reviews confirmed that the Nursing Home Administrator (NHA) was aware of the reporting requirements and the two-hour timeframe for reporting allegations involving abuse, but chose not to notify law enforcement. The NHA based this decision on a subsequent interview with the resident, during which the resident reportedly no longer felt the incident was abuse. Despite this, the initial allegation was not reported to law enforcement as required, and the NHA was uncertain about the resident's feelings at the time the incident was first reported.
Failure to Implement Preventative Action After Alleged Misappropriation
Penalty
Summary
The facility failed to ensure preventative action was taken following an allegation of misappropriation of a resident's property. A resident with severe cognitive impairment and multiple medical diagnoses was reported by family members to have missing cash from their wallet. The family regularly counted the resident's money and noticed that two $50 bills were missing over a two-day period. The incident was reported to facility administration, and both the resident and family members were interviewed. The facility searched the resident's room but was unable to locate the missing money. There was disagreement among family members regarding whether the resident may have hidden the money, but no resolution was reached regarding the missing funds. Despite the facility's policy requiring analysis of such occurrences and implementation of preventative measures, including staff education, no staff education related to misappropriation was completed following the incident. The Nursing Home Administrator was unsure if staff education had been provided, and the Director of Nursing confirmed that it had not. The facility did not take further preventative action to address the potential for misappropriation or to prevent recurrence, as required by their own policies.
Inadequate Infection Control and Reporting in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which was evident during a COVID-19 outbreak in September 2024. The facility's documentation was incomplete, lacking necessary details such as symptom tracking, testing, and outbreak response. The Infection Preventionist (IP) was also working as a floor nurse, which limited their ability to manage the infection control program effectively. This resulted in incomplete surveillance documents and inconsistent symptom documentation for five residents who tested positive for COVID-19. The facility did not report the COVID-19 outbreak to the local health department in a timely manner, as required by state regulations. The first staff member tested positive on September 4, 2024, and the first resident on September 5, 2024, but the outbreak was not reported until September 11, 2024. Additionally, the facility experienced an RSV outbreak in March 2024, which was also reported late to the health department. The facility's failure to report these outbreaks promptly was a significant deficiency in their infection control practices. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds or multidrug-resistant organisms (MDROs) as required. One resident with a diabetic ulcer did not have an EBP order or care plan, and another resident with an MDRO had an EBP order but was not placed on EBP. These oversights indicate a lack of adherence to infection control policies and procedures, contributing to the overall deficiency in the facility's infection prevention and control program.
Inadequate Time Allocation for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) dedicated sufficient part-time hours to effectively manage the infection prevention and control program. The Licensed Practical Nurse (LPN) assigned as the IP was also working full-time as a floor nurse, which limited their ability to allocate adequate time to the infection prevention and control responsibilities. The facility's policy required the IP to be employed at least part-time, with hours varying based on the facility's needs, but the LPN was only able to dedicate approximately 2 hours per week to these duties. This was confirmed during an interview with the LPN, who expressed that the time allocated was insufficient for the role's responsibilities. The survey team observed that the facility's infection prevention and control program was not comprehensive, as evidenced by incomplete line lists, lack of symptom tracking, insufficient follow-through on vaccinations, and an incomplete antibiotic stewardship program. These deficiencies were noted during the survey conducted from November 11 to November 13, 2024. The Director of Nursing and the Administrator in Training were present during the interview with the LPN and did not dispute the LPN's statements regarding the inadequate time dedicated to infection prevention and control duties.
Deficiencies in Food Storage, Preparation, and Sanitization Procedures
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, potentially affecting 50 of 53 residents. During a kitchen tour, surveyors observed several food items in the walk-in cooler and dry storage area that were not properly labeled with open or use-by dates, contrary to the facility's policy and the FDA Food Code. Items such as tomato juice, English muffins, bagels, salt, powdered sugar, flour, and sugar were found with only received dates, lacking the necessary open and use-by dates. The Dietary Manager (DM) acknowledged the oversight and admitted to dating errors due to haste. Additionally, the facility did not adhere to safe microwave heating procedures. The Registered Dietician (RD) and DM were observed reheating food in the microwave without covering it, failing to allow the required two-minute standing time for thermal equalization, and not stirring the food to ensure even heating. The RD and DM both acknowledged that the food should have been prepped ahead of time and at serving temperature on the steam table, but did not provide a reason for not observing the two-minute wait time. The facility also failed to test the temperature of sanitizing solutions as required. Although the parts per million (PPM) of the sanitizing solution were recorded, the water temperature was not tested or recorded, as indicated by the crossed-out temperature column on the logs. The DM confirmed that only the PPMs were tested, not the temperature, which is contrary to the manufacturer's instructions for the sanitizing solution. The Nursing Home Administrator expected staff to follow the facility's kitchen policies and procedures, which were not adhered to in this instance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in the unnecessary administration of antibiotics to a resident. The resident, identified as R261, was transferred to the hospital and prescribed Bactrim DS for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Despite the urinalysis culture indicating resistance to Bactrim DS, the resident completed a seven-day course of the antibiotic without the physician being informed of the culture results. This oversight occurred because the facility's policy for monitoring and updating antibiotic use was not followed. The Infection Preventionist (IP) acknowledged that the physician should have been notified about the culture results, which showed resistance to the prescribed antibiotic. The facility's policy required nurses to communicate lab updates, but this was not done in R261's case. The IP also indicated that the process for coordinating antibiotic stewardship activities involved checking a folder in the Director of Nursing's office or the facility's medical record system, which was not adequately followed. This lack of communication and adherence to the antibiotic stewardship program led to the inappropriate use of antibiotics for R261.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to ensure that three residents, identified as R8, R11, and R29, were offered or received the 2024-2025 COVID-19 vaccine. The facility's policy mandates that residents and staff be educated and offered the COVID-19 vaccine, with proper documentation maintained in their medical records. However, upon review, the medical records of R8, R11, and R29 did not indicate whether they received, were offered, or declined the most recent COVID-19 vaccine. This lack of documentation is contrary to the facility's policy, which requires that each resident's medical record include documentation of vaccine education, administration, or declination. The surveyor's review of the medical records revealed that R8 had a declination form dated April 2020, R11 had one from April 2021, and R29 had one from August 2023. Despite these previous declinations, there was no documentation regarding the 2024-2025 COVID-19 vaccine. The Infection Preventionist confirmed the absence of documentation for these residents, indicating a failure in the facility's process to ensure compliance with their vaccination policy.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R15, to the Nursing Home Administrator (NHA) and the State Agency (SA). R15, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital with a head injury following a fall from a Hoyer lift. During a subsequent hospitalization for aspiration pneumonia, hospital staff discovered a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the thoracic and lumbar spine, none of which were reported by the facility to the SA. The facility's policy on abuse, neglect, and exploitation requires reporting of all alleged violations to the appropriate authorities within specified timeframes. However, the Director of Nursing (DON) indicated that the compression fractures were not reported because the discharge summary did not specifically mention them. The DON acknowledged that an investigation should have been initiated to determine the cause of the fractures and other injuries. Despite being informed by hospital staff about the vaginal tear, the facility did not document or report the injury, and there was no follow-up investigation. Interviews with facility staff revealed a lack of awareness and understanding of the reporting requirements. The DON and Administrator in Training (AIT) were unsure about the suspicion of abuse regarding the fractures, and the Social Worker (SW) failed to document a phone conversation with hospital staff about the vaginal tear. The facility's regional consultant suggested possible causes for the tear but did not confirm any investigation into these possibilities. The NHA did not provide a clear response when asked if the injuries should have been reported to the SA, indicating a gap in the facility's compliance with reporting protocols.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident, identified as R15, who was part of a sample of six residents. R15 was transferred to the hospital with a head injury following a fall from a Hoyer lift and was later hospitalized for aspiration pneumonia. During the hospital stay, R15 was found to have a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the mid and lower back, none of which were investigated by the facility upon R15's return. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of any allegations or suspicions of abuse, neglect, or exploitation. However, the Director of Nursing (DON) acknowledged that the facility did not investigate the compression fractures or the vaginal mucosa tear, despite being notified by hospital staff. The DON admitted that the hospital discharge summary should have prompted an investigation, and the Social Worker (SW) confirmed receiving a call from the hospital about the vaginal tear but failed to document or report it to the nursing staff. Interviews with facility staff, including the Nursing Home Administrator (NHA), DON, and Administrator in Training (AIT), revealed a lack of awareness and action regarding the new injuries discovered after R15's fall. The facility did not conduct interviews with R15 about the injuries, and there was confusion about the responsibility for investigating injuries that may have occurred at the hospital. The regional consultant suggested possible causes for the vaginal tear but confirmed that no investigation was conducted to determine the cause of the injuries.
Failure to Provide Proper Transfer Notification
Penalty
Summary
The facility failed to provide proper notification to a resident, their Power of Attorney (POA), and the State Long-Term Care Ombudsman regarding the resident's transfers to the hospital. The resident, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital on two occasions. On both occasions, neither the resident nor the POA received a written transfer notice, and the Ombudsman was not notified of one of the transfers. The facility's policy required that transfer notices be provided as soon as practicable and that the Ombudsman be notified via a monthly list. During the survey, it was found that the Director of Nursing (DON) signed the transfer notices on behalf of the resident and POA, indicating phone notification, but there was no documentation of the notices being mailed. A handwritten note suggested that the notice was mailed, but it was not returned. Additionally, the Business Office Manager and Social Worker were unaware of the requirement to provide written notices and notify the Ombudsman for transfers to the Emergency Department (ED) when the resident was not admitted to the hospital. This lack of awareness and documentation led to the deficiency in ensuring proper notification for the resident's transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident, identified as R15, and their Power of Attorney (POA) with written information regarding the bed hold policy during two hospital transfers. R15 was transferred to the hospital on two occasions, once after a fall from a Hoyer lift resulting in a head injury and another time due to aspiration pneumonia. Despite these transfers, neither R15 nor their POA received a written notice of the bed hold policy, which includes the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. The facility's policy requires that such notice be provided at the time of transfer or within 24 hours, but this was not adhered to in R15's case. The surveyor's investigation revealed that the facility's staff, including an LPN and the Business Office Manager, were not familiar with the bed hold policy or the process for providing the notice. The Director of Nursing acknowledged that the forms were not signed by R15's POA and there was no documentation to confirm that the notices were mailed. Additionally, the bed hold forms lacked effective dates and daily rates, further indicating a lapse in the facility's adherence to its own policies. This deficiency highlights a failure in communication and procedural compliance regarding the bed hold policy for hospitalized residents.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of a resident, identified as R31, by not honoring their meal preferences during a lunch service. The facility's Meal Distribution and Dining and Food Preferences documents outline the procedures for meal assembly and honoring resident preferences, but these were not followed. During the lunch meal, the Dietary Manager (DM-G) and Registered Dietician (RD-H) were responsible for meal preparation. Despite multiple requests from kitchen staff (CK-I) to prepare French toast for R31, RD-H did not fulfill the request, citing a lack of knowledge on how to make the egg batter recipe. Consequently, R31 did not receive their preferred meal and left the dining area without eating. Interviews with staff and the resident revealed that R31 had a consistent preference for French toast at every meal due to feeling ill with other foods. The Dietary Manager acknowledged awareness of R31's preference and admitted that the meal ticket should have been updated to reflect this. The Registered Dietician later discussed meal preferences and nutrition with R31, who confirmed the desire to continue having French toast for every meal. The failure to provide the requested meal led to R31 leaving the dining room hungry, highlighting a lapse in the facility's adherence to its own policies regarding resident meal preferences.
Failure to Follow Dietary Procedures for Pureed Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that conserved the nutritive value for two residents on pureed diets. The kitchen staff did not follow standardized recipes when preparing pureed food items, which is necessary to maintain the nutritional content of the meals. Specifically, during a lunch service, the Dietary Manager (DM) was observed using water instead of broth or gravy to puree meatloaf and green beans, which diluted the nutritional value of the food. This action was contrary to the facility's contracted food service's policy and the guidelines outlined in the position description for the Cook. Additionally, the facility did not provide all the items listed on a resident's meal ticket. One resident, who was on a regular diet with pureed texture and nectar consistency liquids, did not receive a pureed cranberry muffin as indicated on their meal ticket. The Dietary Manager acknowledged the oversight, stating that the muffin was already pureed and available but was not included with the resident's meal due to nervousness. These deficiencies were confirmed through staff interviews and record reviews, highlighting a failure to adhere to established dietary procedures and policies.
Failure to Administer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered to two residents, R29 and R48, as per CDC guidelines. The surveyor found that R29 and R48's medical records did not contain declination forms for pneumococcal vaccines in 2024, nor were there progress notes indicating that the risks and benefits of the vaccines were discussed with them. According to CDC recommendations, R29 should have been given one dose of PCV15, PCV20, or PCV21, and R48 should have received a dose of PCV15, PCV20, or PCV21 at least one year after their last PPSV23 dose, which was administered in 2000. The Infection Preventionist (IP)-F acknowledged the lack of a system in place for pneumococcal vaccines, as the focus was more on COVID-19 and influenza vaccines. IP-F indicated that the facility's Social Worker is responsible for obtaining vaccine declination forms upon admission, but there was no declination form for R48. IP-F also mentioned that if they become aware of a resident needing a pneumococcal vaccine, they contact the pharmacist to verify which vaccine should be administered and then ask the resident if they want the vaccine.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. The resident, who had been admitted with diagnoses including malignant neoplasm of the esophagus and dysphagia, experienced symptoms of low blood pressure and weakness. Despite these symptoms, the physician was not consulted immediately. The resident's condition included vomiting and diarrhea, which began in the afternoon and continued until the resident was transferred to the emergency room in the evening. The facility's policy required immediate notification of the physician for any significant change in a resident's condition, especially if the symptoms were acute or marked a significant change from usual symptoms. On the morning of the incident, the Director of Nursing was informed of the resident's low blood pressure and reviewed the nurse's notes. Although the physician was contacted about the low blood pressure, this consultation was not documented in the resident's medical record. The resident initially refused to go to the hospital, and the physician was not consulted again until the resident agreed to be transferred later in the day. The nursing staff did not consult the physician after the onset of vomiting and diarrhea, which were new symptoms for the resident. The Licensed Practical Nurse on the afternoon shift reported that the resident had multiple episodes of vomiting and diarrhea but did not contact the physician until the resident's daughter convinced him to go to the hospital. The physician confirmed that he was not informed of the vomiting and diarrhea until the evening, indicating a lapse in communication and adherence to the facility's policy for notifying physicians of significant changes in a resident's condition.
Failure to Develop Comprehensive Care Plan for Chemotherapy Patient
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was admitted with a diagnosis of malignant neoplasm of the esophagus and was undergoing chemotherapy treatment. The care plan did not address the resident's increased risk for infection, risk for dehydration, or abnormal lab values, which required increased monitoring due to the chemotherapy treatments. This deficiency was identified during a review of the resident's records, which showed multiple abnormal lab values and ongoing chemotherapy treatment without a corresponding care plan to guide staff in monitoring and managing these risks. The facility's policy on comprehensive care plans, revised on 9/23/2022, mandates the development of a care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Despite this policy, the care plan for the resident in question did not include necessary interventions or monitoring guidelines related to the resident's cancer diagnosis and chemotherapy treatment. The Nursing Home Administrator in training, who was also the Director of Nursing, acknowledged the expectation for such a care plan to be in place, indicating a lapse in adherence to the facility's care planning process.
Failure to Assess Change in Condition
Penalty
Summary
The facility failed to comprehensively assess a resident's medical status following a change in clinical condition. The resident, who had a history of esophageal cancer and was undergoing chemotherapy, presented with symptoms of low blood pressure and weakness. Despite these symptoms, a comprehensive nursing assessment was not conducted from the morning until the resident's transfer to the hospital in the evening. The facility's policy required frequent monitoring and assessment of the resident's condition, which was not adhered to. The resident experienced new symptoms of vomiting and diarrhea during the afternoon shift, yet no comprehensive assessment of hydration status or other vital signs was performed. The nursing staff did not conduct a Dehydration Risk Screener or any other formal assessment to evaluate the resident's condition, despite the facility's policy and the resident's deteriorating state. The resident's daughter eventually convinced him to agree to hospital transfer, but by then, the opportunity for timely intervention had passed. Interviews with facility staff revealed a lack of appropriate response to the resident's condition. The Director of Nursing acknowledged that a comprehensive assessment should have been conducted, particularly after the second bout of diarrhea. The resident's physician was informed of the low blood pressure but was not updated with further assessments or changes in the resident's condition. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis, secondary to chemotherapy and esophageal cancer.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Freeman Nursing & Rehabilitation Community | 11.3 mi | — | 5 | 0 |
| Optalis Health And Rehabilitation Of Kingsford | 11.5 mi | — | 2 | 0 |
| Iron County Medical Care Facility | 12.9 mi | — | 0 | 0 |
| Maryhill Manor | 15.5 mi | — | 7 | 0 |
| Iron River Care Center | 21.2 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Florence Health Services.
100% money-back within 48 hours.
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.