Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Aviata At Colonial Lakes during CMS and state inspections, most recent first.
Failure to Maintain Resident Privacy During Care: Two residents were observed with privacy curtains that did not fully cover the bed area during care. One resident was cognitively intact and stated the curtain was too narrow, while the other had severe cognitive impairment and was exposed when the curtains separated and opened in the middle. The ES Manager confirmed one curtain was too narrow and the other curtains were not hung with enough overlap to provide privacy.
A resident with quadriplegia, muscle weakness, muscle spasm, and chronic pain reported that his pain was not controlled. The MAR showed repeated missed doses of ordered Dantrium, with nurses documenting the medication as on order or unavailable while other nurses administered it the same day. The pharmacy said the medication had been delivered and should not have run out before reorder dates, and one LPN removed it from the cart because she believed it had been discontinued.
Improper Medication Administration by LPN: An LPN prepared a resident’s crushed scheduled medications and poured them into the resident’s breakfast, then left the room while a CNA continued feeding the resident. The LPN later acknowledged the CNA was administering the medication outside scope of practice and that the nurse should have remained with the resident during administration. The DON verified that CNAs were not trained or qualified to administer medications and that the facility’s procedure required the nurse who prepared the medication to administer it.
Incomplete documentation for IM haloperidol given for agitation. A resident with multiple neuropsychiatric diagnoses and documented behavioral dysregulation had several one-time IM haloperidol administrations for agitation, but the chart did not consistently record the behaviors or rationale supporting the medication use. An RN reported the resident was aggressive and punched her before one dose, while the DON stated the order would have required clarification and that nursing documentation should include the behaviors and interventions leading to the medication administration.
A resident with multiple medical conditions had a midline IV site with a dirty, partially detached dressing covered by gauze, which was not changed as required by facility policy and professional standards. Nursing staff failed to recognize and address the need for a dressing change over several days, despite ongoing IV therapy and regular site assessments.
A resident on a dysphagia mechanical soft diet was allowed to consume an inappropriate snack, leading to a choking incident and hospitalization. The CNA, aware of the dietary restrictions, mistakenly allowed the resident to eat a peanut butter and jelly sandwich, resulting in acute respiratory failure. The facility's failure to ensure staff were knowledgeable about dietary needs led to substandard care at the Immediate Jeopardy level.
A resident on a mechanical soft diet choked on a peanut butter and jelly sandwich after a CNA, lacking specific training on diet types, allowed the resident to consume it. The incident led to the resident being hospitalized with acute respiratory failure. Interviews revealed that staff, including CNAs and LPNs, had not received adequate education on diet types and food textures, contributing to the deficiency.
A resident with dysphagia and dementia experienced a choking incident after grabbing unsuitable food, highlighting the facility's failure to update her care plan to address known behaviors. Despite staff awareness of her tendency to grab food and eat quickly, these behaviors were not documented or discussed in clinical meetings, leading to inadequate care planning.
A resident with severe cognitive impairment experienced unresolved grievances related to missing personal items, including dentures and clothing, at an LTC facility. Despite reports to staff, grievances were not filed or resolved in a timely manner, highlighting systemic issues in grievance handling and documentation.
A resident with a history of multiple health issues, including diabetes and dementia, was readmitted with a UTI and required more assistance with personal care. The resident's daughter reported a decline in her mother's condition, but the facility failed to document these changes in the medical records. The facility's policy required documentation of any changes in condition, but the records lacked entries reflecting the daughter's concerns, leading to a delay in addressing the resident's condition.
The facility failed to adhere to Enhanced Barrier Precautions for residents with urinary catheters by not using PPE and lacking proper signage. Additionally, an LPN did not follow the manufacturer's guidelines for cleaning a shared glucometer, using an alcohol prep pad instead of the recommended disinfecting wipes.
A resident with multiple medical conditions, including cardiomyopathy and diabetes, missed a neurology appointment due to the facility's failure to arrange transportation. Despite an order specifying the need for transportation, the facility did not contact the service, as confirmed by the DON and Unit Manager. The resident, who was cognitively intact, was not taken to the appointment, and the Administrator could not provide documentation of any attempt to arrange transport.
The facility failed to store raw foods properly, leading to potential contamination of ready-to-eat foods. Surveyors found liquid dripping onto produce, improperly stored food items, and unsanitary conditions in the kitchen. The dish machine was not functioning correctly, and juice dispenser nozzles were neglected. Despite multiple visits, issues persisted, violating the facility's food storage and equipment policies.
The facility failed to maintain the walk-in refrigerator in safe condition, affecting 154 residents. The refrigerator's condenser leaked onto food products, creating a wet floor with a puddle. The CDM reported the issue had persisted for over six months and informed Maintenance and Administration. The facility's policy required equipment to be clean, sanitary, and in proper working order.
The facility failed to maintain clean and soiled utility rooms, leading to improper storage of linens and inadequate handwashing supplies on two units. Observations revealed disorganized and dirty conditions, with open soiled laundry bins and obstructed handwashing sinks. The Infection Preventionist and Unit Manager confirmed these issues, noting that housekeeping staff were not cleaning and restocking supplies as required.
A resident was found with medications on her nightstand without a physician's order or self-administration evaluation. The facility's policy requires these steps for safe self-administration, but they were not followed, leading to a deficiency.
A facility failed to update a resident's fall care plan with new interventions after each fall, despite the resident's history of falls and cognitive impairment. The care plan, last revised in May 2024, did not include new strategies for falls that occurred, contrary to the facility's Fall Management policy. The Regional Nurse Consultant confirmed the absence of new interventions for multiple falls.
A resident with double vision did not receive a timely eye appointment despite multiple requests from the provider. The resident, who was not cognitively impaired, had an order for an optometry/ophthalmology consultation, but the Social Service Director was not informed until months later. The facility's Medical Consultation policy was not followed, leading to a delay in care.
The facility failed to document consent, refusal, or contraindication for the Pneumococcal vaccine for two residents. One resident, a male with multiple health issues, and another, a female with various conditions, were admitted without proper vaccine documentation. The Regional RN noted the transition of the Infection Preventionist Nurse role, and the facility's policy requires offering the vaccine within 30 days of admission.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to ensure resident privacy for 2 of 2 residents reviewed for privacy. Resident #90 was admitted with diagnoses including acute respiratory failure, weakness, anxiety, and diabetes. Her MDS quarterly assessment showed a BIMS score of 15/15, indicating she was cognitively intact, and she required substantial to maximal assistance for personal hygiene. During observation, she stated the middle curtain dividing the room was too narrow and did not provide privacy during care. The curtain was observed fully extended with spaces on either side that exposed the head and foot of the bed, and a CNA confirmed the curtain was too narrow to provide privacy during care. Resident #159 was admitted with diagnoses including dementia, spinal cord injury, anxiety, hypertension, kidney failure, and depression. His MDS quarterly assessment showed a BIMS score of 3/15, indicating severe cognitive impairment, and he was dependent on staff for care including personal hygiene. Observations showed the curtains between the two beds were opened in the middle, exposing him to people outside the room, and later the curtains were moving and separated, exposing his mid-section to anyone passing by the open door. The Environmental Services Manager confirmed one curtain in resident #90's room was only 64 inches wide and not wide enough to provide complete privacy, and he also noted the curtains in resident #159's room were not hung appropriately to ensure enough overlap for privacy. The NHA stated his expectation was that each resident's privacy be respected and acknowledged the curtains should be wide enough to provide privacy during care.
Missed Ordered Pain Medication
Penalty
Summary
The facility failed to administer Dantrium (dantrolene sodium) as ordered for a resident admitted with quadriplegia, muscle weakness, muscle spasm, chronic pain due to trauma, and an unspecified cervical spinal cord injury. The resident’s MDS showed he was cognitively intact with a BIMS score of 15 out of 15 and that pain occasionally interfered with sleep. On observation, the resident stated his pain was not controlled and that the medication he received did not seem to relieve his pain, and he had already told staff about this concern. Review of the March 2026 MAR showed the medication was ordered three times daily, but multiple doses were missed across the month. Nursing notes documented that on several occasions the medication was “on order” or “not available until next week per pharmacy,” while other nurses were able to administer doses on the same day. The pharmacy technician stated the medication had been delivered previously and that it should not have run out before reorder dates. One LPN stated she removed the medication from the cart because she believed it had been discontinued, while another LPN acknowledged she did not find the medication in the cart, did not access the Pyxis, and did not follow up further after being told it was too early to refill. The DON reviewed the MAR and notes but could not explain why some nurses documented the medication as unavailable while others administered it, and stated her expectation was that nurses follow the physician’s orders and look for the medication.
Improper Medication Administration by LPN
Penalty
Summary
The facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide medication administration according to standards of care for resident #186, who was admitted with diagnoses including type 2 diabetes mellitus, severe dementia, major depressive disorder, brief psychotic disorder, seizures, hypertension, dysphagia, and adult failure to thrive. During observation of medication administration, an LPN prepared the resident’s scheduled medications, including Colace, Lamotrigine, Losartan, a multivitamin, Tradjenta, Zinc, and Metformin, then crushed them and stated she would ask whether the resident wanted them in food or fluids. The LPN then took the crushed medications to the resident’s room and poured them over the resident’s breakfast, stating the resident was a feeder and this was the only way she would take her medication. The resident was being fed by a CNA when the LPN left the room, and the CNA continued feeding the resident while the medication was being given. The LPN later acknowledged that the CNA was administering the medication, that this was outside the CNA’s scope of practice, and that she should have administered the medication herself and remained with the resident to ensure it was taken safely and completely. The DON verified that the nurse who prepared the medication should be the one to administer it, that CNAs were not qualified or trained to administer medications, and that the facility did not employ QMAs.
Incomplete documentation for IM haloperidol given for agitation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for mood and behavior, resident #31. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, autistic disorder, pseudobulbar affect, gender identity disorder, major depressive disorder, mild cognitive impairment, mild neurocognitive disorder with behavioral disturbance, mood disorder, anxiety disorder, and noncompliance with medical treatment and regimen. The care plan identified the resident as transgender and preferring she/her pronouns, and included behaviors such as refusing medications and care, crawling on the floor, cursing at staff, accusatory behavior, attention-seeking behavior, physical aggression, and verbal abuse. A psychology consult noted ongoing mood lability with increasing agitation and behavioral dysregulation, with recent psychotropic medication adjustments still in progress. The resident had physician orders for one-time IM haloperidol for agitation on multiple occasions. The EMAR showed haloperidol was administered on 3/23/26 at 12:13 PM, 3/25/26 at 1:17 AM, and 3/29/26 at 11:05 PM. The progress note for the 3/23/26 dose documented increased agitation, aggressive behaviors including hitting staff and throwing objects, attempts at verbal redirection and de-escalation, and notification of the provider before the one-time IM haloperidol order was received and carried out. However, the progress notes did not document the rationale for the haloperidol administration at the time it was given on 3/25/26, and did not document the behaviors that required haloperidol or the rationale for its use on 3/29/26. During interview, the RN stated that on 3/25/26 the resident became aggressive and yelling and punched her, and that she called the physician for an IM haloperidol order. She stated she did not pull the medication from the emergency medication kit and used a box of haloperidol IM in the medication cart, but could not remember the dose and confirmed she did not give it orally. The DON stated that an order written for a 2 mg tablet of haloperidol to be given IM would need clarification before administration, and she could not explain how the medication was given if the pharmacy did not supply it and the emergency medication kit did not stock 2 mg haloperidol. She also stated the expectation was for nurses to document behaviors leading up to haloperidol administration and all interventions used prior to administration. Facility policy required the person administering the medication to document the complaints or symptoms for which the drug was administered in the resident's medical record.
Failure to Provide Timely IV Dressing Change per Standards
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper midline intravenous (IV) dressing care for a resident with multiple complex medical conditions, including a left great toe abscess, stroke, diabetes, heart failure, peripheral vascular disease, elevated white blood cell count, and lymphedema. The resident was observed with a transparent dressing on her right upper arm midline IV site that was dirty, partially detached, and covered with gauze. The Unit Manager acknowledged that the dressing should have been changed earlier, as the presence of gauze required a dressing change every 48 hours according to standard nursing practice and facility policy. Despite ongoing IV therapy and regular flushing of the midline IV, nursing staff failed to recognize and address the need for a dressing change over a period of several days. Record review showed that nursing orders required regular assessment and care of the IV site, including flushing, measurement, and evaluation for signs of infection. The facility's policy and training materials specified that midline catheter dressings should be changed every 5-7 days for clear dressings and every 2 days if gauze is used, or sooner if the dressing is soiled or compromised. However, the dressing was not changed as required, and this lapse was not identified by staff during routine care, resulting in noncompliance with professional standards and facility policy for IV site management.
Failure to Follow Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that a resident on a prescribed dysphagia mechanical soft consistency diet was provided with the appropriate food texture, leading to a serious choking incident. The resident, who had a history of Parkinson's disease, dysphagia, and other medical conditions, was allowed to consume a peanut butter and jelly sandwich, which was not suitable for her dietary needs. This oversight occurred when a Certified Nursing Assistant (CNA) left a tray of snacks, including the sandwich, unattended in the dayroom, and the resident, known for grabbing food from others, took the sandwich and began to eat it. The CNA, aware of the resident's dietary restrictions, mistakenly believed the sandwich was soft enough for the resident to consume because she had seen her eat bread before. However, the resident began to choke on the sandwich, leading to a severe medical emergency. The resident was found unresponsive with a low oxygen saturation level, and despite attempts to administer the Heimlich maneuver and suction food from her airway, she required emergency medical intervention. Paramedics were called, and the resident was transported to the hospital, where she was admitted to the Intensive Care Unit with acute respiratory failure due to hypoxia. The incident highlighted a critical lapse in following prescribed dietary orders and ensuring staff were adequately trained and knowledgeable about the specific dietary needs of residents. The CNA involved had not received proper education on the types of foods appropriate for a dysphagia mechanical soft diet, which contributed to the resident's choking incident. The facility's failure to adhere to the resident's dietary requirements resulted in substandard quality of care at the Immediate Jeopardy level.
Removal Plan
- CNA A received a teachable moment regarding appropriate snacks according to diet texture with the DON.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan.
- The RD completed a quality review on residents diet orders and validated with the CDM against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed.
- Resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. The CDM validated that snacks were delivered to the secured pantry.
- Education for staff started and continued. They educated staff on appropriate snacks based on resident diet texture order and the procedure to validate the resident's diet order if needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders.
- The CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedures for snacks. New diet orders would be reviewed during morning clinical meeting.
- Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done with no discrepancies noted.
- A facility wide quality review was begun by Speech Language Pathologist to verify that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed with no discrepancies noted.
- Resident #1 returned to the facility from the hospital with diet texture downgraded to puree. Orders and care plans were updated accordingly to reflect the texture change. The RD followed up with resident #1 with no new recommendations.
- NHA and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective.
- The RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted.
Inadequate Staff Training Leads to Resident Choking Incident
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had the necessary knowledge, skills, and competencies to provide food and snacks to residents according to their care plans and physician orders. This deficiency was identified when a resident, who was on a mechanical soft consistency diet due to conditions such as Parkinson's disease, dysphagia, and dementia, was allowed to consume a peanut butter and jelly sandwich. The CNA, aware of the resident's dietary restrictions, permitted the resident to eat the sandwich because she had seen the resident eat bread before and believed the sandwich was soft enough. The incident occurred when the CNA left a tray of snacks, including the sandwich, unsecured in the dayroom of the memory care unit. The resident, who was seated alone, grabbed the sandwich and began eating it. Shortly after, the resident began choking, leading to a medical emergency. Despite attempts by staff to administer the Heimlich maneuver and suction the resident's airway, the resident became unresponsive and was transported to the hospital, where she was admitted to the Intensive Care Unit with acute respiratory failure and hypoxia. Interviews and record reviews revealed that the CNA had not received specific training on diet types or food textures, which contributed to the incident. The facility's job description for CNAs required them to provide care in accordance with treatment plans, but the CNA's personnel file lacked documentation of competencies related to caring for residents with dysphagia. Additionally, other staff members, including CNAs and LPNs, reported not receiving education on diet types and food textures, highlighting a systemic issue in staff training and competency assessment.
Removal Plan
- CNA A received a teachable moment regarding appropriate snacks according to diet texture with DON.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan.
- The RD completed a quality review on resident diet orders and validated with the Certified Dietary Manager (CDM) against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed.
- Resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. CDM validated that snacks were delivered to the secured pantry.
- Education for staff included recognizing the different diet types and food textures, appropriate snacks for each diet type, and procedure to validate the resident's diet order as needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders.
- CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedure for snacks. New diet orders would be reviewed during morning clinical meeting.
- Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done with no discrepancies noted.
- A facility wide quality review began by Speech Language Pathologist verifying that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed with no discrepancies noted.
- Resident #1 returned to the facility from the hospital with diet texture downgraded to puree. Orders and care plan were updated accordingly to reflect the texture change. Registered Diet (RD) followed up with resident with no new recommendations.
- The Administrator and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective.
- The RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted.
Failure to Address Resident's Unsafe Eating Behaviors
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable goals and interventions for a resident with behaviors that posed a risk to their safety. The resident, who had a history of Parkinson's disease, unspecified psychosis, dysphagia, and dementia, was admitted to the facility from an acute care hospital. The resident's care plan did not adequately address her known behaviors of grabbing food from others, which was a significant risk given her dysphagia diagnosis and need for a mechanically altered diet. On a specific day, a Certified Nursing Assistant (CNA) observed the resident choking on a peanut butter and jelly sandwich, which was not suitable for her prescribed diet. The CNA had assumed the sandwich was safe because she had previously seen the resident eating bread. The incident led to the resident being transferred to the hospital for acute respiratory failure. Despite the resident's known behavior of grabbing food and eating quickly, these behaviors were not documented in her care plan, nor were they discussed in clinical meetings. Interviews with various staff members, including CNAs, Licensed Practical Nurses (LPNs), and the Director of Nursing (DON), revealed that the resident's behavior of grabbing food was known but not formally addressed in her care plan. The facility's policies required that care plans be updated based on changes in resident behavior, but this was not done in this case. The Social Services Department, responsible for behavioral care plans, did not recall discussing the resident's unsafe behaviors during meals, indicating a breakdown in communication and documentation within the facility.
Failure to Resolve Grievances and Document Missing Items
Penalty
Summary
The facility failed to appropriately document, investigate, follow up, and promptly resolve grievances for a resident who had been experiencing issues with missing personal items. The resident, who had severe cognitive impairment and required substantial assistance for daily activities, had her dentures accidentally thrown away by a staff member. Despite the resident's daughter, who is the Power of Attorney, reporting the issue to the facility's previous Administrator and Social Service Director (SSD), no resolution was provided, and the grievance was not filed until several months later. Further issues arose when the resident was moved to a different room, resulting in the loss of additional personal items, including clothing, shoes, a cellphone, and glasses. Although these items were listed on the resident's inventory sheet, and the daughter reported the losses to multiple facility staff members, no grievance was filed, and no reimbursement was offered. The facility's grievance log revealed numerous unresolved grievances, with many not properly documented or assigned for investigation, indicating systemic issues in handling grievances. Interviews with facility staff, including the new SSD and the Social Service Assistant, confirmed that grievances were not being resolved within the required timeframe, often due to department leaders failing to complete investigations or notify residents of resolutions. The facility Administrator acknowledged awareness of unresolved grievances and the lack of documentation to show progress in addressing these issues. The facility's grievance policy mandates prompt resolution and communication with residents, which was not adhered to in this case.
Incomplete Medical Records for Resident with UTI
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was readmitted with new diagnoses, including a urinary tract infection, and required assistance with personal care. The resident had a history of type II diabetes, chronic kidney disease, major depressive disorder, vascular dementia with agitation, and a persistent mood disorder. The resident's daughter, who was the Power of Attorney, noticed a decline in her mother's functional abilities and reported a change in her condition to the facility staff. Despite this, the facility's progress notes lacked documentation of the resident's change in condition, particularly between 10/23/24 and 11/03/24, when the daughter expressed concerns about her mother's altered mental status and medication refusals. The facility's policy required clinical records to be maintained in accordance with professional practice standards to ensure continuity of care. However, the records did not reflect the resident's change in condition as reported by the daughter on 11/04/24. The Director of Nursing and the Medical Director confirmed that any changes in the resident's condition should have been documented, but there was no record of an assessment or documentation of the daughter's concerns. The lack of documentation led to a delay in addressing the resident's condition, which was later diagnosed as a urinary tract infection at the hospital.
Infection Control Deficiencies in PPE Use and Glucometer Cleaning
Penalty
Summary
The facility failed to prevent the potential spread of infection by not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters. Specifically, for one resident, staff did not wear personal protective equipment (PPE) such as gowns while providing high-contact care, including incontinence care. Additionally, there was no signage outside the resident's room to indicate the type of precautions or the required PPE. Another resident with an indwelling urinary catheter also lacked appropriate signage to alert staff of the necessary precautions and PPE for high-contact care. The facility's policy required such signage to reduce the spread of multi-drug resistant organisms. Furthermore, the facility did not follow the manufacturer's guidelines for cleaning and disinfecting shared glucose meters. An LPN used a single-use alcohol prep pad instead of the recommended disinfecting wipes to clean a glucometer after checking the blood sugar of multiple residents. The glucometer's procedure guide specified the use of specific disinfecting wipes to minimize the risk of transmitting blood-borne pathogens, which was not adhered to in this instance.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident to attend a scheduled neurology appointment. The resident, who was cognitively intact with a Brief Interview for Mental Status Summary Score of 15, had a neurology appointment scheduled, with an order for transportation to be arranged by the facility. Despite this, the resident was not taken to the appointment as the facility did not arrange the necessary transportation. Interviews with the Director of Nursing and the 200 Unit Manager confirmed that the facility was responsible for arranging the transportation but failed to do so. The Administrator was unable to provide documentation that the transportation service had been contacted to arrange the transport. This oversight resulted in the resident missing the scheduled neurology appointment.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store raw foods, such as produce, in a manner that reduces the risk of contamination of ready-to-eat foods. During an initial tour of the kitchen, surveyors observed liquid dripping from the refrigerator condenser onto raw produce, including tomatoes and strawberries, creating a wet floor. The Certified Dietary Manager (CDM) acknowledged the unsanitary condition but did not relocate the produce, despite available storage options. Additionally, an open, unsealed box of chocolate chips with mold-like discoloration was found, along with undated hardboiled eggs, which were discarded by the CDM. In the walk-in freezer, opened, unsealed, and undated boxes of tilapia fish and burgers were improperly stored. An unrefrigerated, half-full jar of jelly was also found and discarded for not adhering to the facility's food storage policy. The facility also failed to ensure that dishes and flatware were cleaned and stored under sanitary conditions. The dish machine's temperature dials were non-functional, and the sanitizer concentration was below the required level, leading to the use of paper products for meals. The juice dispenser nozzles were found with a dark, slimy film, indicating neglect in cleaning. Despite multiple visits by surveyors, the raw produce continued to be stored under the dripping condenser, with inadequate measures taken to prevent contamination. The facility's policies required all foods to be stored in accordance with FDA guidelines and equipment to be kept in proper working order, which were not followed in these instances.
Walk-in Refrigerator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the walk-in refrigerator in a safe operating condition, which had the potential to negatively affect the health of 154 out of 166 residents who received food and nutrition by mouth. During an inspection, it was observed that the refrigerator's condenser was leaking liquid onto food products, including raw produce. The floor of the refrigerator was wet, with a puddle measuring approximately 18 inches by 18 inches. The Certified Dietary Manager (CDM) stated that the floor was regularly dry mopped to remove the liquid and that the condenser had been dripping for more than six months. The CDM also demonstrated that the floor underneath the condenser was soft and boggy due to moisture and had informed the Maintenance Department and Administration about the leak. The facility's food service equipment policy, revised in September 2017, required all equipment to be clean, sanitary, and in proper working order.
Inadequate Infection Control in Utility Rooms
Penalty
Summary
The facility failed to maintain clean and soiled utility rooms, leading to improper storage of contaminated and clean linens, and inadequate handwashing supplies on two of the three units. During an observation and interview with the Infection Preventionist (IP) Registered Nurse, who had been in her position for only four days, it was noted that the soiled utility room on the 300/400/500 unit was disorganized, with dirty countertops and floors. The lid on one of the soiled laundry bins was open, exposing soiled linens, and the hand sanitizer was inaccessible. The handwashing sink was obstructed by various items, including crutches and a used CPAP machine, and was not draining properly due to debris. The clean utility room on the same unit was also dirty, with a broken soap dispenser and no garbage can for disposal of soiled paper towels. On the 200 unit, similar issues were observed, with one of the large bins overflowing with soiled laundry, preventing the lid from closing. The hand sanitizer dispenser was empty, and the mini fridge was dirty with a sticky residue. The clean utility room had visibly soiled floors with dead insects. The Unit Manager and IP Nurse validated these concerns, acknowledging that housekeeping staff should clean and restock handwashing supplies daily, and that soiled laundry bins should be kept closed to prevent infection spread. The Housekeeping and Laundry Supervisor confirmed that staff were supposed to clean and maintain these areas daily, but this was not being done according to the facility's policies and national standards for handling and storing laundry.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident, leading to a deficiency in ensuring the safety of self-administered medications. The resident, who was admitted with conditions including a nondisplaced zone 1 fracture of the sacrum, type 2 diabetes, chronic kidney disease, and depression, was found with several medications on her nightstand, including a nasal spray, Tylenol PM, Magnesium, and Cranberry extract. These medications were brought to her by her son, and there were no physician orders or self-administration evaluations completed for these medications. The Licensed Practical Nurse (LPN) and the Unit Manager confirmed that the necessary protocols for self-administration, such as obtaining a physician's order, completing a self-administration evaluation, and initiating a care plan, were not followed. The facility's policy requires these steps to be completed before a resident can self-administer medications, and a lock box should be provided for safe storage. The Regional nurse also confirmed that no self-administration evaluation assessment had been completed for the resident prior to the surveyor's observation.
Failure to Update Fall Care Plan After Each Incident
Penalty
Summary
The facility failed to review or revise the individualized fall care plan for a resident after each fall, as required by their policy. The resident, who was admitted from an acute care hospital, had a history of falls, difficulty walking, paranoid schizophrenia, anxiety disorder, and dementia. The resident was cognitively impaired and required significant assistance with activities of daily living. Despite these needs, the care plan, which was last revised in May 2024, did not include new interventions for each fall the resident experienced. The Regional Nurse Consultant acknowledged that the care plan lacked new individualized interventions for falls that occurred on specific dates, as well as other falls identified in the resident's medical record. The facility's Fall Management policy, revised in 2019, mandates updating the care plan and Nurse Aide Kardex with interventions after each fall. However, the resident experienced five falls without the care plan being updated with new interventions, indicating a failure to adhere to the facility's policy.
Failure to Schedule Timely Vision Care Appointment
Penalty
Summary
The facility failed to ensure a resident received a timely appointment for vision care, resulting in a deficiency. The resident, who was admitted with diagnoses including hypoglycemia, adjustment disorder, anxiety disorder, and symbolic dysfunctions, was not cognitively impaired and had adequate vision according to the Annual Minimum Data Set assessment. Despite having an order for an optometry/ophthalmology consultation on 4/19/24 and a subsequent ophthalmology appointment order on 7/17/24, the resident did not receive an eye appointment until 7/30/24. The resident had been experiencing double vision in the left eye and had requested to see an eye doctor multiple times, as noted in physician progress notes dated 4/19/24, 5/09/24, 5/30/24, and 7/08/24. The Social Service Director (SSD) and the 300/500 Unit Manager (UM) both confirmed that the provider had requested an eye appointment for the resident on several occasions, but the SSD was not informed of the request until 7/17/24. The SSD acknowledged that an appointment should have been scheduled on 4/19/24 when the provider first requested it. The UM, who started working at the facility on 5/23/24, also confirmed the oversight and stated he was not informed of the need for an eye appointment until notified by social services on 7/17/24. The facility's Medical Consultation policy requires nursing to initiate a Request for Consultation when a medical staff member orders a consultation, which was not followed in this case.
Failure to Document Pneumococcal Vaccine Consent
Penalty
Summary
The facility failed to provide proof of consent, refusal, or medical contraindication for the Pneumococcal vaccine for two residents. Resident #105, a male with diagnoses including protein calorie malnutrition, dysphagia, malignant neoplasm of the prostate, anemia, and chronic obstructive pulmonary disease, was admitted without documentation of vaccine consent or refusal. Similarly, Resident #129, a female with conditions such as muscle weakness, type 2 diabetes, dysphagia, hypertension, cerebrovascular disease, syncope, and collapse, also lacked documentation regarding the Pneumococcal vaccine. The Regional RN confirmed that the previous Infection Preventionist Nurse had left, and a new one had recently started. The facility's policy, revised in October 2019, mandates that all residents be offered the Pneumococcal vaccine upon admission, with eligibility assessed and the vaccine offered within 30 days unless contraindicated or previously vaccinated. However, this policy was not followed for the two residents in question.
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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.
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Nursing homes near Winter Garden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Health Central Park | 2.4 mi | ★★★★★ | 0 | 0 |
| Winter Garden Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 5 | 0 |
| Vivo Healthcare West Orange | 4.5 mi | ★★★★★ | 2 | 2 |
| Lake Bennet Center For Rehabilitation & Healing | 5.1 mi | ★★★★★ | 0 | 0 |
| Orlando Health Center For Rehabilitation | 5.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.