| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 06/16/2021 | Complaint | IOG3 | None | None | None | NoneNone | None |
| 07/08/2020 | Fire/Life/Safety | 0ZS7 | None | None | None | NoneNone | None |
| 06/08/2020 | | XHGT | None | None | None | NoneNone | None |
| 11/26/2019 | Fire/Life/Safety | M2Y4 | K0211 | F | 3 | MEANS OF EGRESS - GENERALMeans of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1 | 12/26/2019 |
| 11/26/2019 | Fire/Life/Safety | M2Y4 | K1051 | F | 3 | PLANS SUBMITTAL PRIOR TO WORK(1) No construction work, including demolition, shall be started until prior written approval has been provided by the Agency's Office of Plans and Construction. This includes all construction of new facilities and all additions, modifications, alterations, renovations, and refurbishing to the site, facility, equipment or systems of all existing facilities.
(2) Approval to start construction only for demolition, site work, foundation, and building structural frame may be obtained prior to construction document approval when the following is submitted for review and approval:
(a) Preliminary Stage II approval letter from the Agency's Office of Plans and Construction.
(b) Construction documents and specifications for all work to be undertaken.
(c) A life safety plan indicating temporary egress and detailed phasing plans indicating how the areas to be demolished or constructed are to be separated from all occupied areas when demolition or construction is in and around occupied buildings.
(3) Projects that have been submitted to the Agency for review will be considered abandoned and will be terminated after any of the following has occurred:
(a) Construction has not begun within one year after written approval of the construction documents from the Agency's Office of Plans and Construction;
(b) No further plans have been submitted for Agency review within one year after a project has been initiated with the Agency's Office of Plans and Construction;
(c) Construction has been halted for more than one year. After termination, resubmission as a new project will be required.
(4) When construction is planned, either for new buildings, additions, alterations or renovations to existing buildings, the plans and specifications must be prepared and submitted to the Agency's Office of Plans and Construction for approval by a Florida registered architect and a Florida registered professional engineer. An architecture or engineering firm, not practicing as a sole proprietor, must provide proof of registration as an architecture or engineering firm with the Florida Department of Business and Professional Regulation.
Florida Administrative Code 59A-4.134(1)-(4) & Florida Building Code (2017) 6th edition Section 450.1.
| 02/13/2020 |
| 11/14/2019 | Standard | M2Y4 | F0641 | D | | ACCURACY OF ASSESSMENTS§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status. | 12/14/2019 |
| 11/14/2019 | Standard | M2Y4 | N0071 | D | 3 | COMPONENTS OF CARE PLAN(1) Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of:
(a) Physician's orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential.
(b) A preliminary nursing evaluation with physician's orders for immediate care, completed upon admission.
(c) A complete, comprehensive, accurate and reproducible assessment of each resident's functional capacity which is standardized in the facility, and is completed within 14 days of the resident's admission to the facility and every twelve months, thereafter. The assessment must be:
1. Reviewed no less than once every 3 months;
2. Reviewed promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem, in the resident's physical or mental condition; and,
3. Revised as appropriate to assure the continued accuracy of the assessment.
| 12/14/2019 |
| 04/03/2019 | Complaint | 9YLR | F0623 | C | | NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). | 05/03/2019 |
| 04/03/2019 | Complaint | 9YLR | F0655 | C | | BASELINE CARE PLAN§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.
§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).
§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary. | 05/03/2019 |
| 04/03/2019 | Complaint | 9YLR | N0506 | C | 4 | DISCHARGE/ TRANSFER NOTICEThe notice required by subsection (7) must be in writing and must contain all information required by state and federal law, rules, or regulations applicable to Medicaid or Medicare cases. The agency shall develop a standard document to be used by all facilities licensed under this part for purposes of notifying residents of a discharge or transfer. Such document must include a means for a resident to request the local long-term care ombudsman council to review the notice and request information about or assistance with initiating a fair hearing with the department's Office of Appeals Hearings. In addition to any other pertinent information included, the form shall specify the reason allowed under federal or state law that the resident is being discharged or transferred, with an explanation to support this action. Further, the form must state the effective date of the discharge or transfer and the location to which the resident is being discharged or transferred. The form must clearly describe the resident's appeal rights and the procedures for filing an appeal, including the right to request the local ombudsman council review the notice of discharge or transfer. A copy of the notice must be placed in the resident's clinical record, and a copy must be transmitted to the resident's legal guardian or representative and to the local ombudsman council within 5 business days after signature by the resident or resident designee.
| 05/03/2019 |
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