Inspection Details

Facility ID: 11911132 | Generated: 2025-11-25

Survey DateInspection TypeTrack IDDeficiencyClassRequirement DescriptionCorrection DateRequirement Long Description
6/5/2024 12:00:00 AMStandard9IMWNoneNoneNoneNoneNone
8/10/2021 12:00:00 AMStandardSO3BA0165Class 3RISK MGMT & QA; ADVERSE INCIDENT REPORT10/15/2021
429.23 Internal risk management and quality assurance program; adverse incidents and reporting requirements.- (1) Every facility licensed under this part may, as part of its administrative functions, voluntarily establish a risk management and quality assurance program, the purpose of which is to assess resident care practices, facility incident reports, deficiencies cited by the agency, adverse incident reports, and resident grievances and develop plans of action to correct and respond quickly ...
7/2/2019 12:00:00 AMStandard7HD5NoneNoneNoneNoneNone
6/5/2017 12:00:00 AMStandardQV8YA0032Class 3RESIDENT CARE - ELOPEMENT STANDARDS07/27/2017
(8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility ' s name, address, an...
6/5/2017 12:00:00 AMStandardQV8YA0093Class 3FOOD SERVICE - DIETARY STANDARDS07/27/2017
(2) DIETARY STANDARDS. (a) The meals provided by the assisted living facility must be planned based on the current USDA Dietary Guidelines for Americans, 2010, which are incorporated by reference and available for review at: http://www.flrules.org/Gateway/reference.asp?No=Ref-04003, and the current summary of Dietary Reference Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National Academies, 2010, which are incorporated by reference and available for rev...
6/5/2017 12:00:00 AMStandardQV8YAL241Class 3LMH - RECORDS07/27/2017
429.075 (3) A facility that has a limited mental health license must: (a) Have a copy of each mental health resident's community living support plan and the cooperative agreement with the mental health care services provider or provide written evidence that a request for the community living support plan and the cooperative agreement was sent to the Medicaid managed care plan or managing entity under contract with the Department of Children and Families within 72 hours after admission. The ...
10/25/2016 12:00:00 AMStandardCXIFA0093Class 3FOOD SERVICE - DIETARY STANDARDS12/20/2016
(2) DIETARY STANDARDS. (a) The meals provided by the assisted living facility must be planned based on the current USDA Dietary Guidelines for Americans, 2010, which are incorporated by reference and available for review at: http://www.flrules.org/Gateway/reference.asp?No=Ref-04003, and the current summary of Dietary Reference Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National Academies, 2010, which are incorporated by reference and available for rev...
9/8/2016 12:00:00 AMMonitorXT5HA0152Class 3PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER12/20/2016
(3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or ...
4/26/2016 12:00:00 AMComplaint1U8FA0056Class 3MEDICATION - LABELING AND ORDERS-
(7) MEDICATION LABELING AND ORDERS. (a) The facility may not store prescription drugs for self-administration, assistance with self-administration, or administration unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S., and Rule 64B16-28.108, F.A.C. If a customized patient medication package is prepared for a resident, and separated into individual medicinal drug containers, then the following information must be recorded on each individual container: 1. The ...
4/26/2016 12:00:00 AMComplaint1U8FA0058Class 3PHARMACY & DIETARY; UNCORRECTED DEFICIENCIES-
429.42 Pharmacy and dietary services.- (1) Any assisted living facility in which the agency has documented a class I or class II deficiency or uncorrected class III deficiencies regarding medicinal drugs or over-the-counter preparations, including their storage, use, delivery, or administration, or dietary services, or both, during a biennial survey or a monitoring visit or an investigation in response to a complaint, shall, in addition to or as an alternative to any penalties imposed under s. ...
2/3/2016 12:00:00 AMComplaint1U8FA0054Class 3MEDICATION - RECORDS-
(5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed in subsection (2), the facility must keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider ' s name, the resident ' s name, the date dispensed, the name and strength of the drug, and the directions for use. (b) The facility must maintain a daily medication observation record (MOR) for each ...
11/13/2015 12:00:00 AMComplaint1U8FA0025Class 3RESIDENT CARE - SUPERVISION02/03/2016
429.26 (7) The facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care pr...
11/13/2015 12:00:00 AMComplaint1U8FA0027Class 3RESIDENT CARE - ARRANGEMENT FOR HEALTH CARE02/03/2016
(3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate resident access to health care as needed, the facility must: (a) Assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. (b) Provide transportation to needed medical, dental, nursing or mental health services, or arrange for transportation through family and friends, volunteers, taxi cabs, public buses, and agencies providing transportation. (c) The f...
11/13/2015 12:00:00 AMComplaint1U8FA0052Class 3MEDICATION - ASSISTANCE WITH SELF-ADMIN02/03/2016
(3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) Any unlicensed person providing assistance with self administration of medication must be 18 years of age or older, trained to assist with self administered medication pursuant to the training requirements of Rule 58A-5.0191, F.A.C., and must be available to assist residents with self-administered medications in accordance with procedures described in Section 429.256, F.S. and this rule. (b) In addition to the specifications of Section 429.256(3), F.S...
11/13/2015 12:00:00 AMComplaint1U8FA0079Class 3STAFFING STANDARDS - LEVELS02/03/2016
(3) STAFFING STANDARDS. (a) Minimum staffing: 1. Facilities must maintain the following minimum staff hours per week: Number of Residents Staff Hours/Week 0-5 168 6-15 212 16- 25 253 26-35 294 36-45 335 46-55 375 56- 65 416 66-75 457 76...
11/13/2015 12:00:00 AMComplaint1U8FA0092Class 3FOOD SERVICE - GENERAL RESPONSIBILITIES02/03/2016
(1) GENERAL RESPONSIBILITIES. When food service is provided by the facility, the administrator, or an individual designated in writing by the administrator, must be responsible for total food services and the day-to-day supervision of food services staff. In addition, the following requirements apply: (a) If the designee is an individual who has not completed an approved assisted living facility core training course, such individual must complete the food and nutrition services module of the cor...
11/13/2015 12:00:00 AMComplaint1U8FA0152Class 3PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER02/03/2016
(3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or ...
5/28/2015 12:00:00 AMStandardR0TIA0025Class 3RESIDENT CARE - SUPERVISION07/22/2015
429.26 (7) The facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care pr...
5/28/2015 12:00:00 AMStandardR0TIA0032Class 3RESIDENT CARE - ELOPEMENT STANDARDS07/22/2015
(8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility ' s name, address, an...
5/28/2015 12:00:00 AMStandardR0TIA0052Class 3MEDICATION - ASSISTANCE WITH SELF-ADMIN07/22/2015
(3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) Any unlicensed person providing assistance with self administration of medication must be 18 years of age or older, trained to assist with self administered medication pursuant to the training requirements of Rule 58A-5.0191, F.A.C., and must be available to assist residents with self-administered medications in accordance with procedures described in Section 429.256, F.S., and this rule. (b) In addition to the specifications of Section 429.256(3), F....
5/28/2015 12:00:00 AMStandardR0TIA0078Class 3STAFFING STANDARDS - STAFF07/22/2015
(2) STAFF. (a) Within 30 days after beginning employment, newly hired staff must submit a written statement from a health care provider documenting that the individual does not have any signs or symptoms of communicable disease. The examination performed by the health care provider must have been conducted no earlier than 6 months before submission of the statement. Newly hired staff does not include an employee transferring without a break in service from one facility to another when the facili...
5/28/2015 12:00:00 AMStandardR0TIA0081Class 3TRAINING - STAFF IN-SERVICE07/22/2015
(2) STAFF IN-SERVICE TRAINING. Facility administrators or managers shall provide or arrange for the following in-service training to facility staff: (a) Staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aides trained in accordance with Rule 59A-8.0095, F.A.C., must receive a minimum of 1 hour in-service training in infection control, including universal precautions, and facility sanitation procedures before providing personal care to resi...
5/28/2015 12:00:00 AMStandardR0TIA0082Class 3TRAINING - HIV/AIDS07/22/2015
(3) HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNE DEFICIENCY SYNDROME (HIV/AIDS). Pursuant to Section 381.0035, F.S., all facility employees, with the exception of employees subject to the requirements of Section 456.033, F.S., must complete a one-time education course on HIV and AIDS, including the topics prescribed in the Section 381.0035, F.S. New facility staff must obtain the training within 30 days of employment. Documentation of compliance must be maintained in accordance with subsection (...
5/28/2015 12:00:00 AMStandardR0TIA0160Class 3RECORDS - FACILITY07/22/2015
The facility must maintain required records in a manner that makes such records readily available at the licensee ' s physical address for review by a legally authorized entity. If records are maintained in an electronic format, facility staff must be readily available to access the data and produce the requested information. For purposes of this section, " readily available " means the ability to immediately produce documents, records, or other such data, either in electronic or...
5/28/2015 12:00:00 AMStandardR0TIA0162Class 3RECORDS - RESIDENT07/22/2015
(3) RESIDENT RECORDS. Resident records must be maintained on the premises and include: (a) Resident demographic data as follows: 1. Name; 2. Sex; 3. Race; 4. Date of birth; 5. Place of birth, if known; 6. Social security number; 7. Medicaid and/or Medicare number, or name of other health insurance carrier; 8. Name, address, and telephone number of next of kin, legal representative, or individual designated by the resident for notification in case of an emergency; and 9. Name, address, and teleph...
5/28/2015 12:00:00 AMStandardR0TIAL241Class 3LMH - RECORDS07/22/2015
429.075 (4) A facility with a limited mental health license may enter into a cooperative agreement with a private mental health provider. For purposes of the limited mental health license, the private mental health provider may act as the case manager. 58A-5.029 (2) RECORDS. (a) A facility with a limited mental health license must maintain an up-to-date admission and discharge log containing the names and dates of admission and discharge for all mental health residents. The admission and discha...
5/28/2015 12:00:00 AMStandardR0TIAL242Class 3LMH - RESPONSIBILITIES OF FACILITY07/22/2015
429.075 (2) Facilities licensed to provide services to mental health residents shall provide appropriate supervision and staffing to provide for the health, safety, and welfare of such residents. (3d) Assist the mental health resident in carrying out the activities identified in the individual ' s community living support plan (3) RESPONSIBILITIES OF FACILITY. In addition to the staffing and care standards of this rule chapter to provide for the welfare of residents in an assisted living fa...
5/28/2015 12:00:00 AMStandardR0TIAL243Class 3LMH - TRAINING07/22/2015
429.075 (1) To obtain a limited mental health license, a facility must hold a standard license as an assisted living facility, must not have any current uncorrected deficiencies or violations, and must ensure that, within 6 months after receiving a limited mental health license, the facility administrator and the staff of the facility who are in direct contact with mental health residents must complete training of no less than 6 hours related to their duties. Such designation may be made at the ...
4/23/2015 12:00:00 AMComplaintCW0UAL243Class 3LMH - TRAINING05/28/2015
429.075 (1) To obtain a limited mental health license, a facility must hold a standard license as an assisted living facility, must not have any current uncorrected deficiencies or violations, and must ensure that, within 6 months after receiving a limited mental health license, the facility administrator and the staff of the facility who are in direct contact with mental health residents must complete training of no less than 6 hours related to their duties. Such designation may be made at the ...
12/4/2013 12:00:00 AMComplaintP3IXA0030Class 3RESIDENT CARE - RIGHTS & FACILITY PROCEDURES01/16/2014
(6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to resident complaints, and for res...
12/4/2013 12:00:00 AMComplaintP3IXA0126Class 3FISCAL - RESIDENT ACCOUNTING01/16/2014
(7) RESIDENT ACCOUNTING. (a) If the facility provides safekeeping for money or property; holds resident money or property in a trust fund; or if the facility owner, administrator, or staff, or representative thereof, acts as a representative payee; the resident or the resident ' s legal representative shall be provided with a quarterly statement detailing the income and expense records required under subsection (4), and a list of any property held for safekeeping with copies maintained in th...
12/4/2013 12:00:00 AMComplaintP3IXA0167Class 3RESIDENT CONTRACTS01/16/2014
Resident Contracts. (1) Pursuant to Section 429.24, F.S., prior to or at the time of admission, each resident or legal representative shall execute a contract with the facility which contains the following provisions: (a) A list of the specific services, supplies and accommodations to be provided by the facility to the resident, including limited nursing and extended congregate care services if the facility is licensed to provide such services. (b) The daily, weekly, or monthly rate. (c) A list ...
7/24/2013 12:00:00 AMComplaintG386NoneNoneNoneNoneNone
6/19/2013 12:00:00 AMStandardD6CPA0008Class 3ADMISSIONS - HEALTH ASSESSMENT08/20/2013
(2) HEALTH ASSESSMENT. As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a licensed health care provider, as specified in either paragraph (a) or (b) of this subsection. (a) A medical examination completed within 60 calendar days prior to the individual ' s admission to a facility pursuant to Section 429.26(4), F.S. The examination must address the following: 1. The physical and mental status of the resident, including the identific...
6/19/2013 12:00:00 AMStandardD6CPA0030Class 3RESIDENT CARE - RIGHTS & FACILITY PROCEDURES08/20/2013
(6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to resident complaints, and for res...
6/19/2013 12:00:00 AMStandardD6CPA0052Class 4MEDICATION - ASSISTANCE WITH SELF-ADMIN09/18/2013
(3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) For facilities which provide assistance with self-administered medication, either: a nurse; or an unlicensed staff member, who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self-administered medications in accordance with pr...
6/19/2013 12:00:00 AMStandardD6CPA0054Class 3MEDICATION - RECORDS08/20/2013
(5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed under subsection (2), the facility shall keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider ' s name, the resident ' s name, the date dispensed, the name and strength of the drug, and the directions for use. (b) The facility shall maintain a daily medication observation record (MOR) for ...
6/19/2013 12:00:00 AMStandardD6CPA0092Class 3FOOD SERVICE - GENERAL RESPONSIBILITIES08/20/2013
Food Service Standards. (1) GENERAL RESPONSIBILITIES. When food service is provided by the facility, the administrator or a person designated in writing by the administrator shall: (a) Be responsible for total food services and the day to day supervision of food services staff. (b) Perform his/her duties in a safe and sanitary manner. (c) Provide regular meals which meet the nutritional needs of residents, and therapeutic diets as ordered by the resident ' s health care provider for resident...
6/19/2013 12:00:00 AMStandardD6CPA0152Class 3PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER08/20/2013
(3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; and 2. Must be maintained free of hazards; and 3. Must ensure that all existing architectural, mechanical, electrical and structural systems and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents shall be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each reside...
6/19/2013 12:00:00 AMStandardD6CPA0160Class 3RECORDS - FACILITY08/20/2013
Records. The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff. (1) FACILITY RECORDS. Facility records shall include: (a) The facility ' s license which shall be displayed in a conspicuous and public place within the facility. (b) An up-to-date admission and discharge log listing the names of all residents and each resident ' s: 1. Date of admission...
6/19/2013 12:00:00 AMStandardD6CPA0181Class 3EMERGENCY MGMT - PLAN APPROVAL08/20/2013
(2) EMERGENCY PLAN APPROVAL. The plan shall be submitted for review and approval to the county emergency management agency. (a) The county emergency management agency has 60 days in which to review and approve the plan or advise the facility of necessary revisions. Any revisions must be made and the plan resubmitted to the county office of emergency management within 30 days of receiving notification from the county agency that the plan must be revised. (b) Newly-licensed facility and facilities...
6/19/2013 12:00:00 AMStandardD6CPAL241Class 3LMH - RECORDS08/20/2013
(2) RECORDS. (a) A facility with a limited mental health license shall maintain an up-to-date admission and discharge log containing the names and dates of admission and discharge for all mental health residents. The admission and discharge log required under Rule 58A-5.024, F.A.C., shall be sufficient provided that all mental health residents are clearly identified. (b) Staff records shall contain documentation that designated staff have completed limited mental health training as required by R...
6/19/2013 12:00:00 AMStandardD6CPAL243Class 3LMH - TRAINING08/20/2013
(8) LIMITED MENTAL HEALTH TRAINING. (a) Pursuant to Section 429.075, F.S., the administrator, managers and staff, who have direct contact with mental health residents in a licensed limited mental health facility, must receive the following training: 1. A minimum of 6 hours of specialized training in working with individuals with mental health diagnoses. a. The training must be provided or approved by the Department of Children and Families and must be taken within 6 months of the facility '...
8/8/2012 12:00:00 AMComplaint9NGRNoneNoneNoneNoneNone