Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apopka Health And Rehabilitation Center during CMS and state inspections, most recent first.
Dishwashing sanitization failed when a low-temperature dishwasher only reached 120 degrees F and repeated chlorine test strip checks did not confirm the required PPM, while the log entry lacked initials and the CDM could not verify whether dishes were sanitized. The facility also served chicken orzo soup from a hot box at 131 degrees F, below the 135 degrees F minimum, and the CDM could not determine why the soup was below safe serving temperature.
A resident with dementia and a court determination of total incapacity had documented upper dentures and a court-appointed legal guardian whose contact information was on file. The resident’s record indicated use of dentures or partials, yet the resident was later observed in the dining room without dentures, and staff believed the dentures had been missing for several weeks. The legal guardian reported not being informed that the dentures were missing, and the ED acknowledged the guardian was not notified because dentures often go missing and later reappear, despite a facility policy requiring notification of the resident’s representative when an incapacitated resident experiences changes requiring decisions.
Late Completion of Comprehensive MDS Assessments: The facility failed to complete Comprehensive MDS annual assessments on time for two residents. One resident with dementia, malnutrition, GT status, convulsions, and mobility impairment had an annual MDS completed 3 days late, and another resident with GT status, seizures, encephalopathy, hemiplegia/hemiparesis, a pressure wound, depression, dementia, malnutrition, contractures, weakness, and aphasia had an annual MDS completed 10 days late. The MDS team acknowledged the late completions and stated assessments were expected by the due date.
Late Quarterly MDS Assessments: Four residents had Quarterly MDS assessments completed after the due date. The MDS Director, MDS Coordinator, and Regional MDS acknowledged the late completions, and the RN stated timely assessments were important so the IDT could recognize and act on condition changes, declines, or concerns. The residents had significant medical histories including stroke, dementia, diabetes, vascular disease, fractures, kidney failure, and weakness.
A resident with bipolar disorder, anxiety, schizoaffective disorder, and other psychiatric and cognitive concerns had a PASRR Level I that required a Level II evaluation, but the facility did not obtain the Level II PASRR. The ADON, who was responsible for PASRRs, stated no Level II had been completed and acknowledged the tracking process for PASRR completion and accuracy was not effective; a later psychiatrist review did not remove the need for Level II because serious mental illness diagnoses remained.
A resident with type 2 DM, a foot ulcer, neuropathy, cellulitis, gait impairment, and depression had an order for Voltaren gel to the left hip TID for pain. The MAR showed multiple entries coded as other/see note, but there was no nursing note or other documentation explaining why the medication was not administered, and the Unit Manager confirmed the lack of documentation.
Failure to Use Required PPE During EBP Care: An OTA and PTA provided high-contact care to a resident on EBP while wearing gloves but not gowns, despite EBP signage and PPE supplies at the room entrance and over the bed. The resident had sepsis, chronic hepatitis C, encephalopathy, failure to thrive, a chest port, and a pleural catheter, and the care plan required staff to follow EBP precautions.
The facility failed to notify the Ombudsman of a resident's transfer/discharge to the hospital. The resident, with multiple complex medical conditions, was hospitalized and readmitted, but the required notice was not found in records or submitted to the Ombudsman. The SSD acknowledged the missing documentation, and the facility could not provide a transmission log for February discharges, affecting fifteen residents.
The facility failed to ensure accurate medical records and proper splint application for two residents. One resident's splint was not consistently applied as per physician's orders, and there was confusion among staff about the task. Another resident's EMR contained progress notes for a different resident, indicating a lack of systematic organization and oversight.
A facility failed to ensure an effective discharge planning process for a resident with multiple diagnoses, leading to a delay in necessary care and services post-discharge. The resident was discharged without required Home Health Care (HHC) services and medical equipment, forcing the resident's son to arrange for these services himself. Facility staff acknowledged the communication breakdown and lack of proper follow-up.
The facility failed to promote the right to self-administer medication for two residents. One resident with moderate cognitive impairment was using Biofreeze without a physician's order or assessment, while another cognitively intact resident was using eye drops without proper authorization. The facility did not follow its policy on assessing residents' ability to self-administer medications.
A resident with multiple health conditions had a care plan indicating a preference for showers on specific days and times, but the facility scheduled her showers on different days and times, leading to her refusal of care. Staff confirmed the discrepancy, and the facility's policy on resident rights was not followed.
A facility failed to honor a resident's DNRO due to a discrepancy in records and lack of communication between hospice and facility staff. The resident was incorrectly listed as a full code, risking unwanted CPR for six weeks.
A facility failed to complete a significant change in status assessment (SCSA) within the required 14-day timeframe for a resident receiving Hospice services. The oversight was due to a lack of communication between Social Services, MDS, and nursing staff, resulting in non-compliance with CMS guidelines.
A facility failed to develop a comprehensive person-centered care plan for a resident receiving Hospice services due to a lack of communication between Social Services, MDS, and nursing staff. The resident's medical record lacked a care plan for Hospice or end-of-life care despite having a Hospice Medicare Election form and certification of terminal illness.
The facility failed to provide adequate ADL assistance for two residents, resulting in poor personal hygiene and unkempt appearances. One resident had long, unkempt fingernails and greasy hair, while another had long facial hair and reported not receiving razors despite requests. The facility's policies and care plans were not consistently followed.
The facility failed to apply a right-hand resting splint per physician order for a resident with hemiplegia and hemiparesis following a stroke. Observations revealed the splint was not applied, and staff interviews indicated a lack of training and responsibility in applying the splint after the resident was discharged from therapy.
A resident with multiple diagnoses, including a non-healing wound, had a midline IV with a bloody gauze pad under the transparent dressing that was not changed for four days. LPNs responsible for the resident's care failed to inspect and change the dressing as required, posing an infection risk. The facility's policies for IV site care were not followed, contributing to the deficiency.
Dishwashing Sanitization and Hot Food Temperature Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions during dishwashing operations when the commercial dishwasher was malfunctioning. During an initial kitchen tour, the Certified Dietary Manager demonstrated the low-temperature dishwashing process and the temperature gauge reached a maximum of 120 degrees F. He stated that sanitizer levels were also checked with litmus paper to confirm chlorine at 50-100 PPM, but repeated attempts with two sets of strips showed no color change. Review of the dishwasher log posted near the machine showed a breakfast entry documenting 120 degrees F and sanitizer at 100 PPM, but the entry had no initials. A Dietary Aide assigned to dishwashing said he had used the dishwasher earlier but did not use the test strips and did not document in the log. The CDM could not determine who recorded the sanitizer level, stated the log was documented in error, and acknowledged there was no way to determine whether the dishes were sanitized. The facility also failed to ensure hot food was served at safe temperatures. During lunch meal service, chicken orzo soup in the hot box was observed at 131 degrees F. The CDM acknowledged that accepted food safety standards require hot foods to be held at 135 degrees F or higher. He later stated the hot box heating element measured about 175 to 180 degrees F, suggested the soup may have been left on the counter too long before being placed in the hot box, and said the cooking temperature had been recorded at 213 degrees F but was not rechecked before placement in the hot box. The CDM stated he was the only staff member in the kitchen with Safe Serve certification.
Failure to Notify Legal Guardian of Missing Dentures for Incapacitated Resident
Penalty
Summary
The facility failed to notify a court-appointed legal guardian of a significant change involving missing dentures for a resident who had been determined totally incapacitated. The resident was admitted with dementia with behavioral disturbances, and a court determination dated 10/26/23 documented the resident’s total incapacity related to dementia and lack of awareness. On 8/8/24, a legal guardian of person and property was appointed, and the guardian’s name, phone number, and email address were documented in the admission record. The resident’s inventory list dated 7/29/24 showed that the resident had upper dentures, and a monthly summary progress note on 1/19/26 indicated the resident wore dentures or partials. On 1/27/25 at 12:24 PM, the resident was observed in the dining room for lunch without dentures in place. During a phone interview on 1/28/26 at 3:40 PM, the legal guardian reported being unaware that the dentures were missing and stated the facility had never notified her of this issue. On 1/29/26 at 10:05 AM, the Executive Director stated that staff believed the dentures had been missing for approximately three weeks and acknowledged that the guardian had not been notified because dentures often go missing for a few weeks before turning up again. Review of the facility’s “Notification of Changes” policy showed that when a resident is deemed incapacitated, the resident’s representative is to be notified so that they can make necessary decisions, which did not occur in this case.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to timely complete Comprehensive MDS Assessments for 2 of 6 residents reviewed for Resident Assessment, involving residents #77 and #162. Resident #77, a female with diagnoses including dementia, malnutrition, gastrostomy status, convulsions, and abnormality of gait and mobility, had a Comprehensive Annual Assessment with an ARD of 12/27/25 that was completed on 1/13/26, 3 days late. Resident #162, a male with diagnoses including gastrostomy status, seizures, encephalopathy, hemiplegia and hemiparesis after stroke, a right lower leg pressure wound, major depressive disorder, dementia, malnutrition, contractures of both knees, weakness, and aphasia, had a Comprehensive Annual Assessment with an ARD of 12/12/25 that was completed on 1/05/26, 10 days late. During a joint interview, the MDS Director, MDS Coordinator, and Regional MDS acknowledged that the assessments were completed late and stated the expectation was for completion by the due date, 14 days after the ARD. The RN stated timely assessment completion was important so the IDT would recognize and act on condition changes, declines, or concerns, and said assessments were tracked on a list with due dates reviewed in daily meetings. The facility's standards and guidelines stated the RAI was used to assess functional capacity and needs, identify problems and strengths, and develop, review, and revise individualized care plans, and that the MDS Coordinator was responsible for tracking and monitoring due dates.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to timely complete Quarterly MDS assessments for 4 of 6 residents reviewed for Resident Assessment, including residents #2, #127, #142, and #151. Resident #2 was admitted with diagnoses including acute osteomyelitis, absence of right toes, dysphagia, type 2 diabetes mellitus, history of stroke, peripheral vascular disease, gait and mobility abnormalities, major depressive disorder, hypertension, and unspecified fall; the most recent Quarterly MDS had an ARD of 12/26/25 and was completed on 1/12/26, 3 days late. Resident #127 was admitted with diagnoses including acute kidney failure, dementia with agitation, major depressive disorder, weakness, and a right foot fracture; the Quarterly MDS with an ARD of 12/28/25 was completed on 1/12/26, 1 day late. Resident #142 was admitted with diagnoses including left hip fracture, encephalopathy, type 2 diabetes mellitus, coronary artery disease, gait and mobility abnormalities, and weakness; the Quarterly MDS with an ARD of 12/26/25 was completed on 1/12/26, 3 days late. Resident #151 was admitted and later re-admitted from an acute care hospital with diagnoses including stroke, left-sided hemiplegia and hemiparesis after stroke, type 2 diabetes mellitus, anxiety disorder, depression, gait and mobility abnormalities, and weakness; the Quarterly MDS with an ARD of 12/31/25 was completed on 1/15/26, 1 day late. During interview, the MDS Director, MDS Coordinator, and Regional MDS acknowledged the assessments were completed late and stated the expectation was completion by the due date, 14 days after the ARD. The RN stated timely completion was important so the IDT would recognize and act on condition changes, declines, or concerns, and said assessments were tracked by a list with due dates reviewed in daily meetings.
Missed Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a positive PASRR Level I who required a Level II evaluation was evaluated for required specialized services. Resident #82 was admitted with diagnoses including cerebral infarction, bipolar disorder, seizures, generalized anxiety, and schizoaffective disorder, and later hospital records also documented head trauma, schizophrenia, bipolar disorder, depression, and dementia. The resident’s most recent PASRR identified anxiety disorder, bipolar disorder, and schizoaffective disorder and indicated that a Level II PASRR was required because of serious mental illness. The resident also had a BIMS score of 10 out of 15, indicating moderately impaired cognition, and care plans documented behaviors related to schizoaffective disorder, bipolar disorder, anxiety, confusion, forgetfulness, agitation, elopement, wandering, shower refusals, and mood problems. The ADON, who was responsible for PASRRs, did not provide a Level II PASRR when requested and stated that none had been completed. She explained that a psychiatrist had reviewed the Level I PASRR months later, but the psychiatrist note only reevaluated the schizoaffective disorder diagnosis and did not eliminate the need for a Level II PASRR because depression, bipolar disorder, and anxiety remained listed as serious mental illness diagnoses. The ADON stated she was the only staff member responsible for ensuring PASRRs were completed and submitted in a timely manner and admitted the tracking process for PASRR completion and accuracy had not been effective, resulting in the missed Level II PASRR.
Failure to Document Non-Administration of Ordered Topical Medication
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and professional standards of practice for one resident who was admitted with diagnoses including type 2 diabetes, foot ulcer, neuropathy, skin infection, lower limb cellulitis, abnormality of gait/mobility, and depression. The resident’s quarterly MDS documented a BIMs score of 15 out of 15, indicating she was cognitively intact. Review of the MAR showed an order for Voltaren External Gel 1% to be applied to the left hip three times daily for pain. On multiple occasions, the MAR contained an entry code of 9, which the facility legend identified as other/see note, but there was no documentation explaining why the medication was not administered. On interview, the 200 Unit Manager stated a nursing note should correspond to documentation of other on the MAR and confirmed there was no documentation showing the medication was given or why it was not given. She also stated the process for this topical medication differed because it was kept in the procedure cart instead of the medication cart.
Failure to Use Required PPE During EBP Care
Penalty
Summary
Facility staff failed to use appropriate PPE when providing high-contact care to a resident on Enhanced Barrier Precautions (EBP). Resident #194 was admitted with diagnoses including sepsis, chronic viral hepatitis C, encephalopathy, and failure to thrive, and admission records showed the resident had a right chest port and a right pleural catheter. The resident’s care plan, initiated on 01/12/26, indicated the resident required EBP and that staff were to follow precaution signage and protocol. On 1/28/26 at 10:32 AM, an OTA and a PTA obtained the resident’s blood pressure, assisted the resident from sitting at the side of the bed to a lying position, and boosted the resident up in bed. Both staff members were observed wearing gloves but not gowns. They acknowledged they were not wearing gowns, stated they did not know the resident was on EBP, and confirmed they had seen the EBP signage at the room entrance and over the bed, along with PPE supplies at the entrance. On 1/29/26, the DON and ADON acknowledged the breach of EBP during care provided the previous day.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure a copy of the notice for transfer/discharge to the hospital was sent to a representative of the Office of the State Long-Term Care Ombudsman for one resident. The resident, who had multiple complex medical conditions including metabolic encephalopathy, hemiplegia/hemiparesis following a stroke, and acute and chronic respiratory failure, was hospitalized and readmitted to the facility. However, the required Nursing Home Transfer and Discharge Notice for the resident could not be found in the clinical records or the Social Services Director's (SSD) binder, and there was no evidence that the notice was submitted to the Ombudsman as required. The SSD, who was recently hired, acknowledged the missing documentation and explained that she was informed all documents would be scanned into the facility's electronic medical record. Despite providing a Nursing Home Transfer and Discharge Notice dated for the resident, there was no documentation to indicate it was submitted to the Ombudsman's office. Additionally, the facility could not provide a transmission log for February discharges, and a review revealed that fifteen residents were discharged to the hospital during that period without proper notification to the Ombudsman. The facility also failed to provide a corresponding policy or procedure regarding the notification of discharges.
Deficiencies in Medical Record Accuracy and Splint Application
Penalty
Summary
The facility failed to ensure medical records were accurate regarding the application of a splint for a resident with hemiplegia and hemiparesis following a stroke. The physician's order required the splint to be applied to the resident's right wrist following morning care and removed before bedtime, with monitoring of skin integrity. However, observations revealed the splint was not applied on multiple occasions, and there was ambiguity in the Treatment Administration Record (TAR) about whether the task being signed off was the application of the splint or the monitoring of skin integrity. Interviews with staff indicated confusion and lack of training regarding the application of the splint, leading to inconsistent care and documentation for the resident. The facility also failed to maintain accurate and systematically organized medical records for another resident. The resident's Electronic Medical Record (EMR) contained twenty progress notes that belonged to a different resident. This error was acknowledged by the Regional Director of Clinical Services and the Executive Director, who noted that the Health Information Coordinator was on leave and that the discrepancy had been reported to the facility's Corporate office. The Executive Director admitted to not knowing who was responsible for reviewing the residents' EMRs to ensure accuracy. These deficiencies highlight significant lapses in the facility's adherence to professional standards for maintaining accurate medical records and ensuring proper care for residents. The issues with the splint application and the misfiled progress notes indicate a need for better training, clearer documentation practices, and more rigorous oversight of medical records to prevent such errors from occurring in the future.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident, leading to a delay in necessary care and services post-discharge. The resident, who had multiple diagnoses including a left hip fracture, stroke, and brain cancer, was discharged home without the required Home Health Care (HHC) services. Despite having a care plan that included arranging community resources and medical equipment, the resident was discharged without a walker and necessary wound care supplies. The resident's son had to arrange for HHC services and purchase a walker himself after discovering that the initially referred HHC agency was not in-network with their insurance. The medical record indicated that the resident required assistance with activities of daily living and had a wound that needed daily dressing changes. The facility's Social Services Director (SSD) failed to ensure that the HHC services and medical equipment were arranged before discharge. The SSD relied on an outside HHC agency to make arrangements, but there was no follow-up to confirm that these services were in place. The resident's son reported the issues to the facility, but the necessary services were not provided until three days after the discharge. Interviews with facility staff confirmed that the discharge planning process was not adequately managed. The Business Office Manager and the Administrator acknowledged the communication breakdown and the lack of proper documentation and follow-up by the SSD. The facility's policy required the Social Services staff to oversee discharge arrangements and ensure a safe transition, which was not adhered to in this case. The failure to provide the necessary care and services as ordered by the physician led to a significant lapse in the resident's post-discharge care.
Failure to Promote Right to Self-Administer Medication
Penalty
Summary
The facility failed to promote the right to self-administer medication for two residents. Resident #87, who had moderate cognitive impairment and was using Biofreeze for pain relief, was found to have the medication at his bedside without a physician's order or an assessment for safe self-administration. The Unit Manager and the assigned nurse were unaware of the medication's presence and confirmed that no proper documentation or assessment had been completed for the resident to self-administer the medication safely. Similarly, Resident #161, who was cognitively intact and managing her own eye drops since admission, was found with both prescription and non-prescription eye drops at her bedside. The resident had been using these medications without a physician's order or an assessment to verify her capability to self-administer them safely. The Unit Manager confirmed that the facility's policy and procedures for self-administration of medications were not followed, as there was no documentation or assessment for the resident's ability to self-administer the medications. The facility's policy on self-administration of medications requires an assessment of the resident's mental and physical abilities, comprehension of medication labels, and understanding of the purpose, dosage, and administration times. However, in both cases, the facility did not implement these procedures, resulting in residents having medications at their bedside without proper authorization or assessment, thereby failing to ensure the safe self-administration of medications.
Failure to Honor Resident's Preferred Shower Schedule
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred shower days and times. Resident #21, who has diagnoses including hemiplegia, morbid obesity, heart failure, and type 2 diabetes, was admitted to the facility and had a care plan indicating a preference for showers on Monday, Wednesday, and Friday during the day shift. Despite this, the resident's bathing task report showed she was scheduled for showers on Tuesday and Friday during the 3-11 PM shift. The resident expressed her preference to staff, but her requests were not accommodated, leading to her refusal of showers on several occasions. Interviews with the resident, CNAs, and the Licensed Practical Nurse Unit Manager confirmed the discrepancy between the resident's care plan and the actual shower schedule. The Assistant Director of Nursing also verified that the resident's scheduled shower days did not align with her preferences. The facility's Resident Rights policy emphasizes the importance of honoring resident choices, but in this case, the facility did not adhere to the resident's preferred shower schedule, thus failing to support her self-determination and choice.
Failure to Honor Resident's DNRO
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate Order (DNRO) for a resident who was under hospice care. The resident, who had multiple serious health conditions including cerebral infarction, acute kidney failure, and idiopathic pulmonary fibrosis, had a DNRO signed by both herself and the hospice physician. However, the facility's records and care plan incorrectly listed her as a full code, meaning that in the event of cardiac or respiratory arrest, CPR would be initiated. This discrepancy was not identified until a surveyor brought it to the facility's attention, despite the DNRO being present in the hospice notebook at the nurses' station. The issue was compounded by a lack of communication between the hospice staff and the facility staff. The hospice nurse who admitted the resident did not document any communication with the facility staff regarding the change in code status. As a result, the facility staff, including the usual day nurse for the resident, were unaware of the DNRO and would have initiated CPR based on the incorrect full code status in the facility's records. This failure persisted for six weeks, during which the resident's wishes for a DNRO were not honored, posing a significant risk to her autonomy and end-of-life care preferences.
Failure to Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within the required timeframe of 14 days for a resident who was receiving Hospice services. The resident, who had multiple diagnoses including cerebral infarction, acute kidney failure, idiopathic pulmonary fibrosis, acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia, was admitted and readmitted to the facility. Despite the resident signing the Medicare Election Statement for Hospice services and having a physician order for Hospice services, the facility did not complete the SCSA within the required 14-day period. The most recent Minimum Data Set (MDS) assessment was conducted on 1/23/24, and no SCSA was found in the resident's medical record after the Hospice election date of 2/15/24. The Registered Nurse MDS Coordinator confirmed that the SCSA had not been initiated due to a lack of communication between Social Services, MDS, and nursing staff. The usual process of updating care plans, Advanced Directives, and initiating the SCSA during morning or clinical meetings was not followed. The MDS Coordinator acknowledged that the SCSA was out of compliance and was only brought to their attention by the surveyor. According to the CMS Resident Assessment Instrument Manual, an SCSA is required when a terminally ill resident enrolls in a hospice program, and it must be performed within 14 days to ensure a coordinated plan of care between the hospice and the nursing home.
Failure to Develop Comprehensive End-of-Life Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for end-of-life care for a resident who was receiving Hospice services. The resident, who had multiple diagnoses including idiopathic pulmonary fibrosis, stroke, and acute kidney failure, was admitted and readmitted to the facility. Despite having an intact cognitive status and requiring partial to moderate assistance with activities of daily living, the resident's medical record lacked a care plan for Hospice or end-of-life care, even though a Hospice Medicare Election form and certification of terminal illness were present. The deficiency was acknowledged by the Registered Nurse MDS Coordinator, who cited a lack of communication between Social Services, MDS, and nursing staff as the reason for the oversight. The usual process of updating care plans and advanced directives during morning or clinical meetings was not followed, resulting in the failure to initiate a significant change in status assessment and a comprehensive care plan for the resident when she began receiving Hospice services.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of bathing, skin care, and shaving. Resident #134, who has Parkinson's disease and is cognitively intact, was observed with long, unkempt fingernails, greasy hair, and unshaven facial hair. The resident reported receiving infrequent bed baths and showers, and the Unit Manager confirmed that the resident's fingernails were excessively long and that his feet showed signs of inadequate hygiene. The resident's care plan indicated he should receive three bed baths or showers weekly, but records showed inconsistencies in this care being provided. Resident #87, who has moderate cognitive impairment and multiple diagnoses including congestive heart failure and type 2 diabetes, was observed with an unkempt appearance and long facial hair. The resident reported asking for razors for three days without receiving any and stated that staff had not offered to shave him recently. The Unit Manager confirmed the resident's need for shaving and noted that the resident's care plan required substantial assistance with bathing and personal hygiene tasks. The shower schedule indicated the resident should have showers twice weekly, but there was no documentation of refusal of ADL care. The facility's policy and procedure for ADL care and assistance, as well as the CNA job description, require staff to assist residents with bathing, grooming, and maintaining personal hygiene according to their care plans. However, the observations and interviews revealed that the facility did not consistently provide the necessary care, leading to deficiencies in the residents' personal hygiene and overall well-being.
Failure to Apply Right-Hand Resting Splint Per Physician Order
Penalty
Summary
The facility failed to ensure that a right-hand resting splint was applied per physician order and the resident's plan of care for a resident with hemiplegia and hemiparesis following a stroke. The resident, who had functional limitations in range of motion to one side of his upper and lower extremities, had a physician's order to apply the splint following morning care and remove it before bedtime. However, observations on multiple occasions revealed that the splint was not applied, and the resident confirmed that no one had applied it. The splint was consistently found on the resident's bedside table instead of being worn by the resident. Interviews with staff, including an LPN and a CNA, revealed that the splint had not been applied for several days, and the CNA admitted he was not trained to don/doff the splint. The Rehabilitation Director stated that once the resident was discharged from therapy, nursing staff were responsible for applying the splint. However, the Director of Nursing and Assistant DON acknowledged that the expectation was for nurses to follow physician orders and sign off on the Treatment Administration Record (TAR) to indicate the splint was applied and skin integrity monitored. Despite this, there were inconsistencies in the application and monitoring of the splint, as evidenced by the LPN's admission that she signed off on the TAR without applying the splint.
Failure to Properly Monitor and Change IV Dressing
Penalty
Summary
The facility failed to provide care and services for an intravenous (IV) access site according to professional standards of practice to prevent infection for a resident. Resident #18, who had multiple diagnoses including ischemic cardiomyopathy, type 2 diabetes, and dementia, was receiving Ertapenem via a midline IV for a non-healing right heel wound with osteomyelitis. The resident's care plan included instructions for IV therapy, which required nurses to change the IV dressing and monitor the catheter insertion site every shift for signs of infection and other complications. However, observations revealed that the resident had a bloody, folded gauze pad under the transparent dressing, which had not been changed for four days, posing an infection risk. Licensed Practical Nurse (LPN) M and LPN N, who were responsible for the resident's care, failed to inspect and change the dressing as required. LPN M admitted she had not assessed the IV site during her shift, and LPN N confirmed she had not checked the dressing since the start of her shift, planning to do so only when administering the IV medication. The dressing was dated 3/30/24, and there were no initials to indicate which nurse performed the IV site care. The gauze under the dressing was saturated with blood and yellow-colored fluid, indicating a lack of proper monitoring and timely intervention. The facility's Unit Manager and Regional Director of Clinical Operations acknowledged the issue, noting that the dressing should have been changed more frequently due to the bleeding. The facility's policy and procedure for IV site care required transparent dressings to be changed weekly and gauze dressings to be changed every two days. The failure to adhere to these protocols and the lack of documentation regarding the bleeding and use of gauze contributed to the deficiency, placing the resident at risk for infection.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Apopka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Apopka | 3.1 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Forest Lake | 5.3 mi | ★★★★★ | 0 | 0 |
| Health Central Park | 5.8 mi | ★★★★★ | 0 | 0 |
| Lake Bennet Center For Rehabilitation & Healing | 6.4 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare West Orange | 6.7 mi | ★★★★★ | 2 | 2 |
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