Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record reviews, and interviews, the facility failed to provide written notification of
Transfer/Discharge to Resident Representatives for two (Resident #19 and Resident #12) of four sampled
residents for hospitalizations.
Findings included:
1) On 9/8/21 at 10:40 a.m., Resident #19 was observed lying in the bed covered with a blanket. An attempt
to interview the resident revealed the resident to be confused and unable to answer any questions related
to care and services.
A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on
[DATE] with diagnoses of congestive heart failure, hypertension, chronic obstructive pulmonary disease,
dysphasia, anxiety, Diabetes Mellitus, chronic kidney disease, and dementia.
A review of Minimum Data Set, dated [DATE], for Resident #19 revealed a Brief Interview of Mental Status
score of 03, indicating severe cognitive impairment.
A review of the medical record revealed Resident #19 had an order to send to the emergency room for
evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the
resident was sent to the emergency room for further evaluation via 911 call for an ambulance.
A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge
Notice completed on 6/6/21 for Resident #19. The first page of the form indicated a Resident
Representative with name, address, and phone number listed. The reason for discharge/transfer was listed
as needs cannot be met in this facility. The second page of the form had the name of the Resident
Representative written in and a date of 6/6/21. Verbal Consent was written under the signature line.
On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for
Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer
that took place on 6/6/21. He stated the facility always called him, but he could not state that he received
anything officially in writing.
2) On 9/09/21 at 4:11 p.m., Resident #12 was observed lying in the bed with the head of the bed elevated.
The resident was observed with a tube feeding running via pump at 45 milliliters per hour.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
105777
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The resident was moaning continuously. The resident was not able to communicate or answer any
questions related to care and services.
A review of the Resident Face Sheet (undated), revealed Resident #12 was admitted to the facility on
[DATE] with diagnoses of hemiplegia and hemiparesis after cerebral vascular accident (right side), aphasia,
dysphasia, abnormal posture, gastrostomy, and dementia.
A review of Minimum Data Set for Resident #12, dated 6/13/21, revealed a Brief Interview of Mental Status
score unable to be determined due to the resident being rarely/never understood.
A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for
evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the
resident was sent to the emergency room for further evaluation via ambulance.
A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge
Notice completed on 8/5/21 for Resident #12. The first page of the form indicated a Resident
Representative with name, address, and phone number listed. The reason for discharge/transfer was listed
as needs cannot be met in this facility. The second page of the form had the name of the Resident written in
and unable to sign with a date of 8/5/21.
On 9/9/21 at 4:21 p.m., an interview was conducted with the Administrator and the Director of Nursing. The
Administrator stated the transfer document and Ombudsmen notice was her responsibility once a resident
was transferred. She stated she got the transfer document ready, and she faxed the document to the
Ombudsmen's office. The Administrator stated she did not send a copy of the transfer form to the Resident
Representative in the event the Resident did not have capacity for health care decision. The Administrator
and the Director of Nursing stated they were not aware the documents needed to be sent in writing to
Resident Representatives. The Administrator confirmed she had not sent the written notifications for
transfer to either Resident Representative for Resident #19 or Resident #12.
On 9/9/21 at 4:45 p.m. a telephone message was left for the Resident Representative listed for Resident
#12. The call was not returned.
A facility policy was requested from the Administrator and Director of Nursing regarding requirements for
written notification of transfer/discharge. The facility stated there was no such policy for this requirement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 2 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record reviews, and interviews, the facility failed to provide written notification of the Bed Hold
Policy to Resident Representatives for two (Resident #19 and Resident #12) of four sampled residents for
hospitalizations.
Findings included:
1) On 9/8/21 at 10:40 a.m Resident #19 was observed lying in the bed covered with a blanket. An attempt
to interview the resident revealed the resident to be confused and unable to answer any questions related
to care and services.
A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on
[DATE] with a diagnosis of congestive heart failure, hypertension, chronic obstructive pulmonary disease,
dysphasia, anxiety, Diabetes Mellitus, chronic kidney disease, and dementia.
A review of Minimum Data, dated 6/28/21, Set for Resident #19 revealed a Brief Interview of Mental Status
score of 03, indicating severe cognitive impairment.
A review of the medical record revealed Resident #19 had an order to send to the emergency room for
evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the
resident was sent to the emergency room for further evaluation via 911 call for an ambulance.
A review of the Bed Hold Policy indicated on 6/6/21, the policy was verbally communicated to the Resident
Representative at 5:18 a.m.
On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for
Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer
that took place on 6/6/21. He stated the facility always calls him, but he could not state that he received
anything officially in writing.
2) On 9/09/21 at 4:11 p.m. Resident #12 was observed lying in the bed with the head of the bed elevated.
The resident was observed with a tube feeding running via pump at 45 milliliters per hour. The resident was
moaning continuously. The resident was not able to communicate or answer any questions related to care
and services.
A review of the Resident Face Sheet( undated), revealed that Resident #12 was admitted to the facility on
[DATE] with a diagnosis of hemiplegia and hemiparesis after cerebral vascular accident (right side),
aphasia, dysphasia, abnormal posture, gastrostomy, and dementia.
A review of Minimum Data Set, dated [DATE], for Resident #12 revealed a Brief Interview of Mental Status
score unable to be determined due to the resident being rarely/never understood.
A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for
evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the
resident was sent to the emergency room for further evaluation via ambulance.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 3 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review of the Bed Hold Policy indicated on 8/5/21 the policy was given to the resident and sent to the
emergency room with resident. The signature line of the bed hold policy had resident unable to sign written
on it.
On 9/9/21 at 4:21 p.m. an interview was conducted with the Administrator and the Director of Nursing. The
Administrator stated nursing was responsible for sending the bed hold policy with the resident if they could
sign the document. The Administrator stated she did not send a copy of the bed hold policy to the Resident
Representative in the event the Resident did not have capacity for health care decision. The Administrator
and the Director of Nursing stated they were not aware the bed hold policy needed to be sent in writing to
Resident Representatives. The Administrator confirmed she had not sent the bed hold policy to either
Resident Representative for Resident #19 or Resident #12.
On 9/9/21 at 4:45 p.m., a telephone message was left for the Resident Representative listed for Resident
#12. The call was not returned.
facility policy was requested from the Administrator and Director of Nursing regarding requirements for
written notification of the bed hold policy. The facility stated there was no such policy for this requirement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 4 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility did not ensure respiratory equipment was stored
appropriately for four (Residents # 191, #192, #193 and #194) of seven sampled residents.
Residents Affected - Few
Findings included:
1) During a facility tour on 09/08/21 at 10:38 a.m., Resident #191's Nebulizer machine was observed on top
of the nightstand, not covered. Resident #191 stated that he used his machine two times daily to take his
medicine. Resident #191 said, they don't clean it. On subsequent tours on 09/08/21 and 09/09/21, the
nebulizer machine was observed on the same spot, on top of the nightstand.
Review of Resident #191's face sheet revealed diagnoses to include COPD (chronic obstructive pulmonary
disease), presence of cardiac pacemaker, presence of automatic (implanted) cardiac defibrillator, and
chronic congestive heart failure
An initial MDS (minimum data set) dated 09/02/21, revealed a BIMS (brief interview for mental status) score
of 15, indicating intact cognition.
Review of Resident #191's physician's order sheet with a print date of 08/30/21, revealed that Resident
#191 received Albuterol 0.5 soln. inhale via nebulizer b.i.d (2 times per day) for COPD (chronic obstructive
pulmonary disease) and
Budesonide Sulphate 0.5mg/2ml inhale 1 vial nebulizer, b.i.d for COPD.
2) During multiple tours on 09/08/21 and 09/09/21 an observation was made of Resident # 192's nebulizer
machine sitting on top of the nightstand uncovered.
A review of Resident #192's physician order sheet printed on 08/26/21, revealed an order; Ipratropium / sol
albuterol dated 08/21/21. Inhale one pre-mixed vial via nebulizer every six hours as needed - diagnosis
shortness of breath.
Ipratropium / sol albuterol 0.5 - 2.5mg/3ml dated 08/30/21. Give one vial via nebulizer every 6 hours for
COPD.
Review of Resident #192's face sheet revealed diagnoses including acute respiratory failure, unspecified
whether with hypoxia or hypercapnia, end stage renal disease, acute embolism, and tracheostomy status.
An initial MDS (minimum data set) dated 08/26/21, revealed a BIMS (brief interview for mental status) score
of 13, indicating intact cognition.
3) Resident #193 was admitted to the facility on [DATE], with diagnoses including heart failure unspecified,
unspecified atrial flutter, and chronic pulmonary disease unspecified.
During multiple tours on 09/08/21 and 09/09/21, Resident # 193's nebulizer was observed stored inside an
opened nightstand drawer, noted uncovered and unlabeled.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 5 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #193's Physician orders sheet printed on 08/30/21, revealed an order dated 08/28/21
for Budesonide 0.5mg/2 inhale one nebule via nebulizer twice daily for COPD.
Ipratropium sol albuterol dated 8/28/21, inhale one nebule via nebulizer every six hours for COPD
An initial MDS (minimum data set) dated 09/02/21 revealed a BIMS (brief interview for mental status) score
of 14, indicating intact cognition.
4) During multiple tours on 09/08/21, 09/09/21 and 09/10/21, Resident #194's nebulizer was observed
inside a drawer on his nightstand noted uncovered and not labeled.
Resident # 194 was admitted to the facility with a diagnoses including pneumonia, unspecified organism,
allergic rhinitis, chronic obstructive pulmonary disease, rhabdomyolysis, and unspecified heart failure.
Review of Resident #194's Physician orders sheet printed on 08/26/21, revealed an order
Ipratropium / sol albuterol dated 08/23/21. Inhale one pre-mixed vial via nebulizer twice daily at 9:00 a.m.
and 9:00 p.m.
Budesonide Sulphate 0.5mg/2ml (order date 08/23/21) inhale one pre-mixed vial via nebulizer twice daily at
9:00 a.m. and 9:00 p.m.
A Baseline care plan for Resident # 194 revealed cognitive status alert and oriented.
A Care plan dated 09/06/21 with a target date of 12/06/21 revealed a goal under chronic obstructive
pulmonary disease, related to COPD. The goal identifies that Resident #194 will have no shortness of
breath and will actively participate in therapy through the next review date. Interventions include to monitor
for shortness of breath and increased respirations. Treatment / medications as ordered.
On 09/10/21 at 12:50 p.m., an interview was conducted with Resident #194. Resident #194 stated that
since he moved into the facility, his nebulizer machine sat in the drawer or on top. He stated he never saw it
in a bag or anything. He stated that he used his nebulizer machine two times daily.
On 09/10/21 at 12:56 p.m., an interview was conducted with Staff A, LPN. Staff A walked into the resident
rooms with the surveyor and made the observations of the nebulizers. She said, It [nebulizer] should not be
laid on top of the nightstand. It should be covered. Staff A said she would get a bag. She stated, All of them
[nebulizers] should be stored in a dated bag.
A follow-up interview was conducted with the NHA (Nursing Home Administrator) on 09/10/21 at 1:33 p.m.
The NHA stated, They [nebulizers] should be stored per policy. The facility's policy was requested.
On 09/10/21 at 4:24 p.m., an interview was conducted with the Regional Director (RD). The RD stated that
the facility did not have a policy related to Nebulizer equipment, use, maintenance, and storage.
An interview was conducted on 09/10/21 at 2:58 p.m. with the DON (Director of Nursing). She said, We are
supposed to have a bag for each equipment, store the face mask and nebulizer mouth pieces in a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 6 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
bag. The nurses should clean the equipment after each use and store accordingly. I will in service and train
the staff. She further stated that she would implement a procedure for cleaning masks, changing tubing,
and dating the bag.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 7 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and record review, the facility did not ensure the kitchen was maintained
in a sanitary manner and food was stored appropriately related to cleanliness of the walk -in cooler and
freezer, storage and dating of opened foods, and repair of a leaking pipe in the dishwashing area.
Findings included:
An initial kitchen tour was conducted on 09/08/21 from 9:15 a.m. to 9:45 a.m., facilitated by Staff E, Cook.
Photographic evidence of the following observations was obtained.
During the tour of the walk -in cooler a 1-gallon bottle of soy sauce was noted with bio growth inside, dated
opened 5/14/2020.
A carton of French vanilla coffee mixer noted please do not use, for Christmas party dated 12/12/19. A
bottle French vanilla coffee mix next to the carton was noted with bio growth inside. Staff E who saw the bio
growth stated, That is not good. we will throw them out.
In the walk-in cooler, a tube of ground beef thawing in a shallow pan was observe on the bottom shelf noted
leaking blood, overflowing to the floor of the cooler.
Above the ground beef that was thawing, a pipe going through the cooler wall was noted with bio-growth on
the base of the pipe.
Bio- growth was also observed on the door to the main freezer within the cooler.
The inside of the freezer was observed with plastic dividers on the doorway, mounted with built up frost and
icicle formations.
Staff E said, Be careful, the floor is slippery because of the melting ice. Staff E stated that this had been an
on-going problem.
The floor of the freezer was noted with brown-looking matter, food crumbs, and red-saucy paste dried on
the floor.
On the freezer shelves, yellow looking-icy melting formations were observed dripping on an opened box of
ice-cream cups.
An unlabeled, undated small bowl with a yellow frozen food item was observed wrapped in plastic food
wrap. Staff E stated, It looks like ice-cream. It should not be there. She stated she would toss it. Staff E
stated that all food items should be labeled and dated.
Staff E was asked how often the freezer and walk -in cooler were cleaned. Staff E said, We should clean
more. Staff E stated that CDM (Certified Dietary Manager) oversees the scheduling.
During a tour of the dry good storage area, a bag of noodles not labeled, dated, or properly sealed was
observed on the shelf.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 8 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105777
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Davenport Nursing and Rehab Center
206 W Orange St
Davenport, FL 33837
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
A tour of the main kitchen area revealed a pipe leaking underneath the dishwashing table. A blue tub was
noted collecting the dripping water and towels laid around to catch the overflow.
On 09/08/21 at 9:39 a.m., an interview was conducted with Staff F, Dietary Aide. Staff F stated that the pipe
had been leaking for a few days, but she could not remember how long. Staff F said, it was recent. The
CDM is aware.
On 09/08/21 at 12:41 p.m., an interview was conducted with the CDM. He stated that they would throw out
the expired food items and clean the freezers. He said that they have called a plumber for the leaking pipe
and are awaiting parts for repairs. The CDM stated that the pipe had been leaking only a few days.
On 09/09/21 at 12:06 p.m., a review of kitchen concerns was discussed with CDM and RD (Registered
Dietician). After reviewing photographic evidence, the CDM stated that he cleaned out the freezer and
cooler and threw out all the items that were expired and that were with bio growth. The CDM said, We
should not have kept it there. It should not be served to the residents. The CDM stated that the freezer door
did not close very well and hence the built-up frost and melting ice. He said he was aware of the on-going
concern. The RD said, All food that is open should be tightly sealed and dated.
On 09/10/21 at 1:33 p.m., an interview was conducted with NHA (nursing home administrator). She said
she was notified by the RD and the CDM of the concerns identified in the kitchen. The NHA said she
understood there was a problem with excessive frosting and some food items not properly stored. She said
her expectation was that the facility maintained a clean and sanitary environment.
Review of an undated facility policy titled, Food Storage revealed that food items should be stored, thawed,
and prepared in accordance with good sanitary practice.
Procedure: all products should be dated upon receipt and when they are prepared. Leftovers should be
dated according to the leftover policy. Remember to cover, label and date
Storage: (3.) Foods to be frozen should be stored in airtight containers or wrapped in heavy duty aluminum
foil or special laminated papers. Label and date all food items.
Thawing: (4.) Thaw meat by placing in deep pans and setting on lowest shelf in refrigerator.
Storage: (2.) The walls, ceiling and floors should be maintained in good repair and regularly cleaned.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105777
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0200GeneralS&S Dpotential for harm
Meet other general requirements.
- 0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0352GeneralS&S Dpotential for harm
Properly install and monitor supervisory attachments on automatic sprinkler systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the September 10, 2021 survey of DAVENPORT NURSING AND REHAB CENTER?
This was a inspection survey of DAVENPORT NURSING AND REHAB CENTER on September 10, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DAVENPORT NURSING AND REHAB CENTER on September 10, 2021?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.