Average — CMS composite of the measures below.
A standard survey is most likely before 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 Aviata At Rosewood during CMS and state inspections, most recent first.
Incomplete QAPI Monitoring and Repeated Deficiencies: The facility failed to maintain an effective QAPI program by not identifying and addressing repeated deficiencies and by not keeping complete monitoring documentation for corrective action plans. A supplemental oxygen-dependent resident was found lethargic and without ordered oxygen, and the DON stated there was no track-and-trend record for the daily checks and weekly audits. The same deficiency areas, including care planning, respiratory care, and medication errors, were identified again on the recertification survey.
A resident with cerebral atherosclerosis, severe vascular dementia, and hospice involvement had DNR status listed in the EMR and on physician orders, but court orders stated no person shall honor any DNR for the resident. The Administrator confirmed the code status was incorrectly documented as DNR and said the record was not reviewed in its entirety, with the facility relying on the DNR form and physician order instead of the full record.
Failure to Develop Comprehensive Care Plan for Actual Skin Impairments: A resident with severe cognitive impairment, total ADL dependence, hospice status, and multiple pressure ulcers had no comprehensive care plan for actual skin integrity alterations despite an MDS documenting several stage 3, stage 4, unstageable, Kennedy terminal, and skin tear wounds. The Assistant MDS LPN and Regional MDS nurse confirmed no care plans were in place for the resident’s actual wounds, and the DON stated the resident should have had a care plan for actual skin impairment on admission/readmission or when the quarterly MDS was completed.
Missed Quarterly Smoking Safety Evaluations: A resident with major mobility impairments, amputations, pain, and intact cognition continued to smoke and participate in smoke breaks, but the facility did not complete the required quarterly smoking safety/risk evaluations. Records showed the assessments had been done previously, then stopped, with two quarterly evaluations overdue and only an incomplete evaluation opened at the end of the survey. The DON acknowledged the missing evaluations, and the facility policy required smoking assessments on admission/re-admission, quarterly, and with changes in condition.
Oxygen Therapy Not Delivered at Ordered Flow Rates: Two residents with respiratory-related diagnoses were observed receiving O2 via NC at flow rates that did not match physician orders. One resident’s concentrator was set below the ordered rate, and the other’s was set above the ordered rate. The assigned RN said she checked O2 sats but forgot to verify the concentrators, and the DON stated nurses were expected to check the liter flow at eye level and provide the O2 ordered by the physician.
Medication administration errors occurred when an RN gave a resident chewable Aspirin 81 mg instead of the ordered delayed-release Aspirin 81 mg and applied a Nicotine patch 14 mg/24 hr instead of the ordered 21 mg patch. The resident had multiple cardiac diagnoses, HTN, nicotine dependence, and CKD stage 2. The RN confirmed the wrong nicotine dose was given because that was what was in the cart, and the DON confirmed the errors and stated medications were expected to be administered as ordered.
A facility failed to obtain timely physician orders for a resident's surgical site care upon readmission. The resident, with a history of fractures, had specific hospital discharge instructions for wound care that were not transcribed into the EMR until two days later. Observations revealed the surgical site was open to air without a dressing, and the LPN acknowledged the oversight. The DON confirmed the expectation for immediate transcription of hospital orders upon readmission.
A facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including multiple sclerosis and hypertension. After a hospitalization, the resident returned to the facility, but the care plan was not updated to reflect her needs. An error by the previous MDS coordinator led to the cancellation of the existing care plan, leaving the resident without an accurate plan for over a month.
A facility failed to document the care of a surgical pin site for a resident with multiple medical conditions. Physician orders required daily cleaning and dressing of the site, but the Treatment Administration Record (TAR) showed blank spaces on several dates, indicating incomplete documentation. The resident refused treatment on two occasions, but there was no record of physician notification. The facility lacked a specific policy for TAR documentation, contributing to the deficiency.
A resident with multiple health conditions was left with a medication cup on her tray table by an RN who documented the medications as administered. The RN was called away for an emergency and did not return to ensure the resident took her medications. The facility's policy requires nurses to ensure medications are taken and not left at the bedside.
A facility failed to adhere to a podiatry treatment plan and schedule a timely follow-up for a resident with diabetes and vascular issues. The resident's treatment was prolonged beyond the recommended period, and a necessary podiatry referral was not scheduled, leading to potential infection concerns.
A resident with a history of stroke and partial paralysis was not provided with a toileting program or necessary assistance to maintain continence, despite being able to sense the urge to void. The facility lacked appropriate equipment to assist the resident to the toilet, and staff were unaware of the resident's continence needs, leading to a deficiency in care.
A facility failed to provide a resident and his responsible party access to medical records after a written request. The resident's brother was authorized to receive the records, but due to a procedural error, the request was not fulfilled. The medical records staff was new, and the receptionist sent the consent forms to the wrong email address, preventing the legal department from receiving them.
A resident with a history of fractures and unsteadiness experienced multiple falls from their wheelchair, but the facility failed to update the care plan with new interventions. Despite identical incidents occurring on two occasions, no changes were made to the care plan, task list, or nurse aide Kardex, as confirmed by the Administrator and Regional Nurse Consultant.
A resident with cognitive impairments and a history of fractures experienced multiple falls from their wheelchair. Despite these incidents, the facility did not update the care plan with new interventions to prevent further falls, as required by their Fall Management policy.
The facility failed to ensure dishware was properly sanitized according to the manufacturer's instructions. Staff continued to use potentially unsanitized plates for meal service, posing a health risk to residents. The issue was identified and addressed only after meal preparation had begun.
The facility failed to obtain physician orders and provide appropriate IV care for two residents, resulting in a lack of adherence to professional standards of practice. The DON and nursing staff acknowledged the deficiencies and the need for proper documentation and care for IV lines.
The facility failed to obtain physician orders and administer oxygen therapy as prescribed for three residents. One resident was observed without her oxygen nasal cannula, another received oxygen at a lower rate than ordered, and a third resident's oxygen was set incorrectly. Nursing staff acknowledged the discrepancies and the importance of verifying oxygen orders.
The facility failed to monitor a resident on Eliquis for potential side effects such as bleeding. Despite the resident's high-risk status, there were no orders or documentation for monitoring, and the facility's policy on anticoagulant therapy was not followed.
A resident missed fourteen doses of prescribed Cephalexin due to a lapse in the facility's medication administration process. Despite the resident's repeated notifications to staff, the medication was not reordered promptly, and the prescribing physician was not informed in a timely manner. The facility's shift change contributed to the error.
A resident with quadriplegia was found with multiple medications at his bedside without proper evaluation or physician's order. The facility staff acknowledged the lack of proper orders and evaluations, and the facility's policy on self-administration of medication at bedside was not followed, leading to the deficiency.
The facility failed to request PASARR level I and level II evaluations after a resident received a new diagnosis of psychotic disorder with delusions. Despite the responsibility of the SSD and DON to ensure timely PASARR evaluations, the required screenings were not completed as per the facility's policy.
The facility failed to develop and implement person-centered care plans for two residents, one with severe cognitive impairment and another on anticoagulant medication. Observations showed that the residents did not receive individualized activities or monitoring for bleeding risks, despite their medical and psychosocial needs. The facility did not adhere to its policies for establishing care plans within the required timeframe.
The facility failed to provide a resident-centered activities program for a resident with severe cognitive impairment and multiple medical conditions. Despite the resident's preferences for music, fresh air, and religious services, she was observed lying in bed without any engagement or entertainment. The activities staff lacked resources and did not know the resident's specific interests, and there was no comprehensive care plan in place.
A resident with dysphagia following a stroke was given the incorrect enteral feed formula, Glucerna 1.5 calorie instead of the prescribed Glucerna 1.2 calorie, on multiple occasions. This discrepancy was confirmed by both the LPN and the Unit Manager, who acknowledged the need to verify the correct formula at the start of each shift. The error was further corroborated by the Registered Dietician and the DON, emphasizing the importance of following physician orders to meet the resident's nutritional needs.
A resident who experienced significant trauma and life changes did not receive trauma-informed care. Despite being cognitively intact and dependent on staff for daily activities, her care plan lacked a post-trauma care plan. The psychiatric APRN focused on medication management without counseling, and the Social Services Director did not ensure a trauma-informed care plan. The Interdisciplinary Team admitted to communication gaps, leading to the deficiency.
A facility failed to maintain a medication error rate below 5% when an LPN administered incorrect dosages of Folic Acid and Guaifenesin to a resident with multiple diagnoses. The errors were confirmed by the LPN and DON, highlighting a deviation from the facility's medication administration policies.
A resident missed 14 doses of Keflex due to a failure in transferring medication orders accurately to the EMR during a system update and shift change. The error was not promptly reported or addressed, and the resident's grievance was not initiated in a timely manner.
The facility failed to ensure accurate documentation of IV dressing changes for a resident with multiple diagnoses. Nurses signed off on the task without performing the dressing change, and the order was not updated when the resident's peripheral line was replaced with a midline catheter. The DON and other staff confirmed the inaccuracies, and the facility did not provide a policy for medical record accuracy.
A facility failed to implement a physician's order for contact isolation precautions for a resident with ESBL in the urine. Despite the order, the correct signage and PPE were not in place, and Enhanced Barrier Precautions were incorrectly used instead.
Incomplete QAPI Monitoring and Repeated Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. On a previous survey dated 4/26/24, CMS enforcements were issued for F0656 (Develop/Implement Comprehensive Care Plan), F0695 (Respiratory/Tracheostomy Care and Suctioning), and F0759 (Free of Medication Error Rate of 5 Percent or More). During the current review, the NHA described the facility’s QAPI process as a four-step system involving identification of deficient practice, investigation of causes, correction of problems, and development of correction plans with goals, timelines, education, retention tools, and audits to determine effectiveness. A joint review of Performance Improvement Plans since the last recertification showed that monitoring documentation for previously identified F0695 concerns was incomplete or missing. The facility had identified a supplemental oxygen-dependent resident on 1/28/25 who was lethargic and without the physician-ordered oxygen, and an Ad Hoc QAPI meeting developed a PIP calling for daily checks and weekly audits to ensure residents received oxygen per physician orders. When asked to review the monitoring documentation and audits, the DON stated there was not a track-and-trend record and that the facility did the checks daily and kept a mental record. During the recertification survey from 9/15/25 to 9/18/25, deficient practice was again identified for F0656, F0695, and F0759. The facility’s undated 2025 QAPI Plan stated that completed PIPs are filed in the QAPI notebook and monitored periodically to assure achievements are sustained.
Incorrect DNR Status in Resident Record
Penalty
Summary
The facility failed to conduct thorough, periodic reviews of Advance Directives to ensure the resident’s resuscitation status was accurately documented in the medical record. Resident #33 was admitted with diagnoses including cerebral atherosclerosis, severe vascular dementia with agitation, a brain bleed, major depressive disorder, and restlessness and agitation. Hospice paperwork showed the resident was admitted to hospice for a terminal diagnosis of cerebral atherosclerosis and later returned to the facility for respite care. The electronic medical record contained a DNR order signed by the resident’s husband, and the physician’s orders also listed the resident as DNR. The resident’s care plan identified advanced directives related to DNR, but the record also included court orders stating the resident lacked capacity to consent to services and that no person shall honor any DNR related to the respondent. The Administrator confirmed the facility incorrectly listed the resident’s code status as DNR and stated the resident should have been Full Code. She acknowledged the facility relied on the DNR form and physician order and did not review the resident’s record in its entirety, including the court documents that nullified the prior DNR order.
Failure to Develop Comprehensive Care Plan for Actual Skin Impairments
Penalty
Summary
The facility failed to develop an individualized Comprehensive Care Plan that included resident #4’s actual skin impairments. Resident #4 was readmitted with diagnoses including cerebral infarction, severe cognitive impairment, total dependence for activities of daily living, and multiple pressure ulcers. The quarterly MDS with an ARD of 6/30/25 documented four unhealed stage 3 pressure ulcers and six unstageable pressure ulcers, including wounds that were facility acquired and others present on readmission. Review of the medical record showed comprehensive care plans for several other conditions, including an indwelling urinary catheter, ineffective airway clearance, hospice, dementia, communication problems, altered cardiovascular status, risk for falls, tube feeding, aspirin therapy, mood problem, risk of malnutrition, and hemiplegia. A care plan revised on 5/20/24 addressed potential for pressure injury development, but it did not identify any of the resident’s actual pressure ulcers or other alterations in skin integrity. The wound assessment report dated 9/10/25 listed active wounds including stage 3 pressure ulcers of the sacrum/right buttock, left upper back, spine, and right lateral ankle; a stage 4 pressure ulcer of the left lateral ankle; an unstageable pressure ulcer of the right ischium; a Kennedy terminal ulcer of the right hip; and a reopened skin tear of the left medial ankle. On 9/16/25, a CNA observed the resident with multiple wound dressings in place. On 9/17/25, the Assistant MDS LPN and Regional MDS nurse confirmed that no care plans had been developed for the resident’s actual skin integrity alterations, and the Regional MDS nurse stated the resident should have comprehensive care plans for both potential and actual alteration in skin integrity. The DON stated the resident was admitted with wounds and that a comprehensive care plan for actual alteration in skin should have been initiated on admission or readmission, or when the quarterly MDS was completed. The facility policy required an individualized person-centered plan of care with measurable objectives and timetables based on the comprehensive assessment.
Missed Quarterly Smoking Safety Evaluations
Penalty
Summary
The facility failed to conduct scheduled smoking safety/risk evaluations for one resident who was reviewed for smoking. The resident was a male with multiple significant impairments, including muscle weakness, pain in the left shoulder, right upper extremity amputation above the elbow, left leg amputation above the knee, right leg amputation below the knee, rotator cuff tear, and polyneuropathy. His most recent Significant Change MDS showed intact cognition, use of a wheelchair, dependence on staff for transfers, and substantial assistance needs for several ADLs. His care plan included a self-releasing safety belt for injury risk in a motorized mobility chair and a smoking-related goal that he would not suffer injury from unsafe smoking practices. The resident and staff reported that he continued to participate in smoke breaks and had been an active smoker for years. Facility records showed smoking evaluations had been completed quarterly through 2/16/25, but no additional quarterly evaluations were completed when they were due in May and August 2025. An incomplete evaluation was opened on the last day of the survey. The DON acknowledged that the resident was missing the required smoking safety evaluations and stated that nursing leadership was responsible for completing them on admission, re-admission, quarterly, and with changes in condition. The facility policy titled Smoking-Supervised required residents who smoke to be evaluated on admission/re-admission, quarterly, and with a change in condition to determine whether assistance or supervision was needed.
Oxygen Therapy Not Delivered at Ordered Flow Rates
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for 2 of 3 residents reviewed for respiratory care. One resident had diagnoses including hemiplegia following a stroke, pressure ulcers, and protein calorie malnutrition, and the MDS indicated severe cognitive impairment, dependence on staff for dressing and personal hygiene, and use of oxygen therapy. The resident’s care plan identified ineffective airway clearance/aspiration related to shortness of breath and use of 2 LPM oxygen continuously via nasal cannula, while the active physician order was for oxygen at 2 LPM via nasal cannula PRN. During observation, the resident was in bed with oxygen tubing connected to a concentrator set at 1.5 LPM instead of the ordered rate. The second resident had diagnoses including COPD, systemic lupus, hypertension, atrial fibrillation, anemia, and chronic kidney disease. The MDS showed moderate cognitive impairment and no oxygen therapy at the time of assessment, while the care plan addressed oxygen therapy for shortness of breath related to COPD and included oxygen at 2 LPM via nasal cannula PRN. The active physician order required oxygen at 2 LPM continuously and directed nurses to check the oxygen delivery every shift. During observation, the resident was in bed with oxygen tubing connected to a concentrator set at 2.5 LPM instead of the ordered rate. The assigned RN stated she had checked both residents’ oxygen saturation earlier but forgot to check the concentrators, and later acknowledged both residents were not receiving oxygen as ordered. The DON stated nurses were supposed to check the oxygen liter flow rate at eye level at least every shift and to give what was ordered by the physician.
Medication Administration Errors
Penalty
Summary
Medication administration errors occurred when RN C failed to follow physician orders for resident #50 during medication pass. The resident was admitted with diagnoses including heart disease, combined systolic and diastolic heart failure, heart muscle damage, hypertension, nicotine dependence, and stage 2 chronic kidney disease. During observation, RN C prepared and administered chewable Aspirin 81 mg from the cart stock bottle instead of the ordered Aspirin 81 mg delayed-release tablet, and she applied a Nicotine patch 14 mg/24 hr to the resident's left upper arm instead of the ordered Nicotine Step 1 patch 21 mg/24 hr. Review of the EMAR showed the physician orders for the delayed-release aspirin and the 21 mg nicotine patch. RN C later confirmed she gave the wrong nicotine patch dose and stated that 14 mg was what was in the cart. The DON confirmed awareness of the medication errors and stated her expectation that medications be administered as ordered by the physician; she also stated that if a medication was not available, a nurse should not administer an alternative dose without consulting the physician. The facility policy required medications to be administered in accordance with prescribed orders.
Failure to Obtain Timely Physician Orders for Surgical Site Care
Penalty
Summary
The facility failed to ensure that admission physician orders for the immediate care of surgical sites were obtained for a resident who was readmitted. The resident, a female with a history of fractures in the right fibula and tibia, was readmitted with surgical wounds requiring specific care. Hospital discharge instructions specified the use of Aquacel dressings and daily dressing changes, but these orders were not transcribed into the facility's electronic medical record (EMR) until two days after readmission. During the survey, it was observed that the resident's surgical site was open to air without a dressing, contrary to the hospital's discharge instructions. The LPN responsible for the resident acknowledged the lack of completed dressing changes and the absence of physician orders for the surgical site care upon readmission. The Director of Nursing confirmed that the admission nurse should have reviewed and transcribed the hospital's discharge orders into the EMR immediately upon the resident's readmission.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive individualized care plan for a resident who was admitted with multiple diagnoses, including multiple sclerosis, major depressive disorder, anxiety, history of falls, and hypertension. After being re-hospitalized for chest pain, the resident returned to the facility, but the care plan was not updated to reflect her current needs. The only focus in the care plan initiated on 10/24/24 was on nutritional problems, despite the resident's complex medical history and recent hospitalization. The deficiency occurred because the previous MDS coordinator incorrectly noted the resident as 'discharge not anticipated,' which canceled the existing care plan. This error left the resident without an accurate care plan from 10/21/24 until 11/25/24. The facility's Plan of Care policy requires an individualized, person-centered plan that includes the resident's strengths and services to achieve their highest practicable well-being, but this was not adhered to in this case.
Failure to Document Surgical Pin Site Care
Penalty
Summary
The facility failed to follow physician orders for the care of a surgical pin site for a resident with multiple medical conditions, including a dislocated tibia, diabetes, and anxiety disorder. The resident was admitted with intact cognition and required substantial assistance for daily activities. Physician orders were in place to clean and dress the surgical pin site daily, but the Treatment Administration Record (TAR) showed blank spaces on several dates, indicating the treatment was not documented as completed. Additionally, there was no documentation to show that the physician was notified when the resident refused treatment on two occasions. The Assistant Director of Nursing/Unit Manager and the Director of Nursing acknowledged the documentation gaps and confirmed that the TAR should not have blank spaces. The facility lacked a specific policy addressing documentation on the TAR, although their medication administration policy required topical treatments to be recorded. The absence of documentation and failure to notify the physician of treatment refusals contributed to the deficiency identified by the surveyors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered per professional standards for a resident. An 81-year-old female resident with diagnoses including end-stage renal disease, diabetes type II, hypertension, chronic pain, and major depressive disorder was observed with a medication cup left on her tray table. The resident stated that the nurse had left the medications there, and she intended to take them momentarily. The nurse, RN A, confirmed that she had left the medications on the resident's tray table and documented them as administered at 9:26 AM. However, RN A was called away for an emergency and did not return to ensure the resident took her medications. The Director of Nursing and the Regional Nurse both stated that medications should not be left at the resident's bedside, and nurses should ensure medications are taken before leaving. The facility's policy on administering medications, revised in April 2019, indicates that if a resident is unavailable to receive medication, the MAR may be flagged, and the nurse should return to administer the medication after completing the medication pass. This incident highlights a failure to adhere to the facility's medication administration policy, as the nurse did not ensure the resident took her medications before leaving the room.
Failure to Follow Podiatry Treatment Plan and Schedule Follow-Up
Penalty
Summary
The facility failed to follow a podiatry treatment plan and ensure a timely follow-up appointment with a podiatrist for a resident with type 2 diabetes mellitus, peripheral vascular disease, and complications following a stroke. The resident had a podiatry visit where a partial nail avulsion was performed, and wound care orders were given for 10 days. However, the facility continued the treatment for 32 days longer than recommended. The Director of Nursing (DON) could not explain why the treatment was prolonged and confirmed that the order should have been discontinued. Additionally, the facility did not schedule a follow-up podiatry appointment despite a referral being made by the attending physician due to concerns about redness on the resident's left great toe. The Social Service Director confirmed that the referral had not been scheduled, and the podiatrist's office stated no service date was set for the facility. An Advanced Practice Registered Nurse (APRN) later examined the resident's toe, noted redness, and suspected remnants of an infection, indicating a need for further medical intervention.
Failure to Provide Continence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate continence care for a resident who was continent of bladder and bowel. The resident, who had a history of stroke, type 2 diabetes mellitus, and partial weakness and paralysis on the left side, was admitted to the facility and was assessed as always incontinent of bowel and bladder. However, no toileting program, such as scheduled toileting or prompted voiding, was attempted upon admission or reentry. The resident expressed that she felt the urge to urinate or have a bowel movement before it happened and would use the toilet if it was offered, but typically went in her adult brief. The MDS Coordinator and the Director of Nursing (DON) were unaware of the resident's ability to sense the need to void before it occurred. The facility lacked mechanical lifts or slings designed to transfer residents to a toilet, which was necessary for the resident who required maximum assistance for toileting. The DON confirmed there was no documentation of a toileting program trial or the offering of a bedpan for the resident since her admission. The failure to implement a toileting program or provide the necessary assistance to maintain the resident's continence led to the deficiency.
Failure to Provide Access to Medical Records
Penalty
Summary
The facility failed to provide a resident and his responsible party access to his personal and medical records following a written request. The resident, who was cognitively intact, had a healthcare power of attorney and authorization for release of protected health information documents on file, designating his brother as the authorized recipient for his medical records. Despite a signed consent form authorizing the release of the medical records to the resident's brother, the facility did not fulfill the request due to a procedural error. The error occurred because the medical records staff, who was new to the position, did not handle the request, and the responsibility was temporarily assigned to the receptionist. The receptionist sent the consent forms to the wrong email address, resulting in the legal department not receiving them. The facility's policy required requests to be granted within 24 hours, and if the legal department did not respond within 72 business hours, a follow-up was necessary. However, due to the email error, the request was not processed, leading to the deficiency.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to revise a fall care plan to include new interventions for a resident who experienced multiple falls. The resident, who had a history of multiple fractures and unsteadiness on feet, was admitted and readmitted with significant injuries. Despite documented incidents on two separate occasions where the resident slid from their wheelchair onto the footrests, the care plan was not updated to reflect these falls or to include any new interventions to prevent recurrence. The deficiency was identified during a review of the resident's medical records and incident reports, which showed that the falls on two different dates were identical in nature. The facility's Administrator and Regional Nurse Consultant confirmed that no new interventions were added to the resident's care plan, task list, or nurse aide Kardex following these incidents. This oversight was acknowledged by the Administrator, who noted that adding an intervention could have reduced the likelihood of the same incident occurring again.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement appropriate fall interventions for a resident who experienced multiple falls. The resident, who had a history of multiple fractures and cognitive impairments, was dependent on staff for daily activities and used a wheelchair for mobility. Despite falling on several occasions, including slipping from the wheelchair onto the footrests, no new interventions were added to the care plan or task list to prevent further incidents. The facility's incident log and medical records showed that the resident fell on multiple dates, but the care plan was not updated with new interventions after these falls. Interviews with staff confirmed that the falls were similar in nature, yet no additional measures were taken to address the issue. The facility's Fall Management policy required updating care plans and nurse aide Kardex with interventions, which was not done in this case.
Improper Sanitization of Dishware
Penalty
Summary
The facility failed to ensure dishware was rinsed with the proper level of sanitizer according to the manufacturer's instructions. During a kitchen observation, staff were seen running dishware through a low-temperature dish machine that uses a chemical sanitizer. The Dietary Manager attempted to test the sanitizer level, which should be at 100 parts per million (ppm), but the test strips did not activate. Despite this, Dietary Aide G continued to remove and stack plates from the machine, mixing potentially unsanitized dishware with sanitized ones. The Dietary Manager did not intervene to stop this practice and left to call the chemical supplier instead. Later, kitchen staff were observed preparing meal trays using the potentially unsanitized plates. The Dietary Manager acknowledged the issue and eventually stopped the tray line to switch to disposable containers. He confirmed that the kitchen would need to re-wash everything after lunch and admitted the health risk posed by serving food on improperly sanitized plates. The dish machine was later tested again and registered the correct sanitizer level of 100 ppm. The Dietary Manager could not explain why he did not stop the dietary staff earlier when he became aware of the sanitization issue.
Failure to Provide Appropriate IV Care and Services
Penalty
Summary
The facility failed to obtain physician orders and provide intravenous (IV) care and services according to professional standards of practice for two residents. Resident #209 was admitted with multiple diagnoses, including sepsis and end-stage renal disease, and had a Peripherally Inserted Central Catheter (PICC) line. The admission nurse did not obtain orders for the care of the PICC line, and the facility staff did not provide any care for the PICC line for 21 days. The resident's dialysis center confirmed they were not responsible for the PICC line care, and the facility staff failed to notice and address the PICC line's presence and care needs. The Director of Nursing (DON) acknowledged the oversight and the lack of care provided for the PICC line during this period. Resident #79 was admitted with diagnoses including left above knee amputation, dysphagia, and end-stage renal disease. The resident had a physician order for IV dressing changes every 72 hours and flushes every shift. However, the facility staff documented dressing changes every shift instead of every 72 hours as ordered. The resident's midline catheter dressing was not changed according to professional guidelines, and the DON confirmed that the physician's order was not adjusted when the midline was inserted. The facility's Treatment Administration Record (TAR) indicated that dressing changes were being checked off as completed every twelve hours, which was not accurate. The facility's failure to provide appropriate IV care and services for both residents resulted in a lack of adherence to professional standards of practice. The DON and other nursing staff acknowledged the deficiencies and the need for proper documentation and care for IV lines. The facility's policies and procedures were not followed, leading to potential risks for the residents involved.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy and did not administer oxygen therapy as ordered for three residents. Resident #11 was admitted with multiple diagnoses including COPD and was observed multiple times without her oxygen nasal cannula in place, despite the concentrator being set at 2.5 LPM. There was no physician order for oxygen in her medical record, and the nursing staff acknowledged the oversight in entering the order into the electronic medical record (EMR). Resident #2, diagnosed with COPD and other conditions, was observed receiving oxygen at 2 LPM, contrary to the physician's order of 3 LPM. The LPN and Unit Manager confirmed the discrepancy and acknowledged the responsibility of the nursing staff to ensure the oxygen flow rate matched the physician's order. The DON reiterated the importance of verifying oxygen orders at the beginning of each shift. Resident #310, with diagnoses including heart failure and chronic respiratory failure, was observed receiving oxygen at 1.5 LPM instead of the prescribed 3 LPM. The LPN and Unit Manager confirmed the incorrect setting and emphasized the nurse's duty to monitor and adjust the oxygen flow rate as per the physician's order. The DON confirmed the necessity of administering oxygen as ordered to prevent respiratory complications.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to provide adequate monitoring for potential side effects of anticoagulant medication for a resident who was on Eliquis. The resident, who had a history of sepsis, respiratory failure, and other serious conditions, was observed with bleeding on his left cheek and forearm. Despite the resident's high-risk status and the known side effects of Eliquis, there were no orders or documentation indicating that nurses monitored for signs of bleeding from the time the medication was prescribed until the deficiency was noted. A registered nurse confirmed that there were no orders to monitor for bleeding, and the Director of Nursing stated that the nurse who entered the anticoagulant order should have included monitoring instructions. The facility's policy on anticoagulant therapy required monitoring for signs of bleeding, but this was not followed in the case of this resident. The lack of monitoring was evident in the nursing progress notes and medication administration records, which showed no evidence of monitoring for side effects of the anticoagulant medication.
Significant Medication Error Due to Lapse in Administration Process
Penalty
Summary
The facility failed to provide care and services to prevent a significant medication error for a resident prescribed oral antibiotic therapy. The resident, who had multiple diagnoses including atherosclerosis, embolism, and thrombosis, was prescribed Cephalexin (Keflex) 500 mg twice daily for an infection. Despite the prescription, the resident missed fourteen doses of the medication due to a lapse in the facility's medication administration process. The resident was readmitted to the facility after hospitalization and initially received the medication, but it was stopped after five days without proper justification or communication with the prescribing physician. The resident repeatedly informed the staff about the missing medication, but no immediate action was taken. The resident even contacted the Infectious Disease physician's office himself to confirm the medication's stop date and brought this information to the nursing staff. Despite this, the medication was not reordered until several days later, resulting in the resident missing fourteen doses. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware of the issue but failed to notify the Infectious Disease physician promptly. The facility's internal processes, including a shift change from 8-hour to 12-hour shifts, contributed to the medication order being dropped from the resident's electronic medical record. The DON and ADON acknowledged the error but did not take immediate steps to rectify the situation or inform the prescribing physician. The resident expressed frustration and concern over the lack of communication and accountability from the facility staff, highlighting a significant lapse in medication administration and oversight.
Failure to Ensure Proper Evaluation and Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure an evaluation for self-administration of medication was completed, failed to obtain a physician's order for self-administration of medications, and failed to ensure medications were not stored at the resident's bedside. Resident #95, who was admitted with diagnoses including quadriplegia and chronic obstructive pulmonary disease, was found with multiple medications at his bedside without proper authorization or evaluation. The resident's cognition was intact, but he was dependent on staff for activities of daily living and mobility needs. The medications included Calazime skin protectant, Diclofenac sodium topical gel, Biofreeze gel, anti-itch cream, and analgesic balm, which the resident stated he brought from a previous rehabilitation facility and had been using for approximately one week without staff intervention or proper storage protocols being followed. The resident also mentioned that the medications provided by the facility did not alleviate his pain and spasms, prompting him to use his own medications. However, there was no documentation or physician's order for self-administration or bedside storage of these medications in the clinical records. The facility's staff, including the LPN, Unit Manager, and DON, acknowledged the lack of proper orders and evaluations for the medications found at the resident's bedside. The DON confirmed that medications should not be kept at the bedside without a physician's order due to safety concerns, and the facility's policy required medications to be stored in a lock box if kept at the bedside. The resident's inability to self-administer medication due to his physical limitations was also noted, and it was revealed that a family member had brought the medications to the facility. The facility's policy on self-administration of medication at bedside was not followed, leading to the deficiency.
Failure to Complete PASARR Evaluations for New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation after a new major mental disorder diagnosis for one of the residents. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, major depressive disorder, and cocaine abuse. On a later date, the resident received a new diagnosis of psychotic disorder with delusions. Despite this new diagnosis, the facility did not complete an updated PASARR level I or trigger a PASARR level II evaluation as required by their policy and federal/state guidelines. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) confirmed that it was their responsibility to ensure PASARR evaluations were completed timely. Both acknowledged that the resident should have had another PASARR level I completed due to the new diagnosis and that a PASARR level II was triggered but not performed. The facility's PASARR policy mandates that all residents with serious mental illness or intellectual disability receive appropriate pre-admission screenings and follow-up evaluations if new diagnoses are made after admission.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, one with severe cognitive impairment and another on anticoagulant medication. Resident #11, who had multiple diagnoses including Alzheimer's disease and hemiplegia, did not have a comprehensive care plan for activities despite her preferences for listening to music, going outside, and participating in religious services. Observations over several days showed that she remained in bed without any diversional activities, and staff did not offer her any activities or get her out of bed. The Activity Director and Activities Assistant confirmed that there was no comprehensive care plan in place for her activities, and the MDS nurses validated that the care plan should have been initiated but was not individualized to her preferences or goals. Resident #209, who was cognitively intact and on high-risk medications including an anticoagulant, did not have a care plan addressing the need for staff to monitor for signs or symptoms of bleeding. The resident was observed with drops of blood on his cheek and forearm, and he mentioned that he bled easily due to the blood thinner. The MDS nurse confirmed that a comprehensive care plan for anticoagulant monitoring should have been initiated but was not. The facility's policies and procedures required an individualized person-centered plan of care to be established within seven days after the completion of the comprehensive assessment, but this was not done for either resident. The lack of comprehensive care plans for both residents indicates a failure to meet their medical, nursing, mental, and psychosocial needs as identified in their assessments. This deficiency was observed through multiple instances of inaction by the staff, including the lack of individualized activities for Resident #11 and the absence of monitoring for bleeding risks for Resident #209. The facility's failure to adhere to its own policies and procedures for developing and implementing care plans contributed to these deficiencies.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide a resident-centered activities program that met the individual interests and needs of a resident, leading to a deficiency. Resident #11, who had severe cognitive impairment and multiple medical conditions including hemiplegia, Alzheimer's disease, and chronic pain, was observed lying in bed without any form of entertainment or engagement such as a TV or radio. Despite her preferences for listening to music, going outside for fresh air, and participating in religious services, there was no documentation of evaluations, progress notes, or care plans regarding activities for her. Repeated observations over several days showed that the resident remained in bed, fidgeting and restless, with no staff offering any diversional activities or getting her out of bed. The activities staff were not observed attending to her needs, and the assigned CNA and LPN did not provide any meaningful engagement or activities tailored to her preferences. Interviews with the Activities Director and Activities Assistant revealed that they were aware of the resident's preferences but lacked the resources to provide individualized activities, such as bedside radios. The Activities Assistant admitted to not knowing the resident's specific interests in reading material or music. The MDS nurses confirmed that there was no comprehensive care plan in place for the resident's activities, despite the psychosocial evaluation indicating her preferences for church on TV, oldies music, romance movies, comedy shows, religious services, news, politics, and current events. This lack of a tailored activities program and the absence of a comprehensive care plan contributed to the deficiency in meeting the resident's needs and interests.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care and services by not following physician orders for a resident with a gastric tube feeding. The resident, who was admitted with diagnoses including dysphagia following a stroke and required tube feeding, was observed to have been given the incorrect enteral feed formula. Specifically, the resident was prescribed Glucerna 1.2 calorie formula to be administered at a rate of 79 ml per hour, but was instead given Glucerna 1.5 calorie formula on multiple occasions. This discrepancy was confirmed by both the Licensed Practical Nurse (LPN) and the Unit Manager, who acknowledged that the correct formula should have been verified at the start of each shift. The error was further corroborated by the Registered Dietician and the Director of Nursing (DON), who emphasized the importance of administering the correct enteral feed formula to meet the resident's nutritional needs. The facility's policy on enteral feeding also mandates that nurses administer the feeding as ordered by the physician. The failure to follow these orders resulted in the resident not receiving the prescribed nutrition, which is critical for their health and well-being.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident who experienced trauma received trauma-informed care. The resident, who was admitted with multiple fractures and later diagnosed with anxiety and major depressive disorder, was cognitively intact and dependent on staff for activities of daily living. Despite her traumatic experience and significant life changes, her electronic medical record did not contain a post-trauma care plan. The resident expressed that no one had talked to her about her trauma, and she did not want to rely solely on medications for her mental health needs. The psychiatric APRN primarily focused on medication management and did not provide counseling, while the Social Services Director acknowledged the resident's significant life changes but did not ensure a trauma-informed care plan was in place. The resident's care plan contained inappropriate interventions and did not address her trauma. The Regional MDS Director confirmed the absence of a trauma-informed care plan and acknowledged the inappropriate intervention in the resident's care plan. The Interdisciplinary Team (IDT) reviewed the psychological progress notes and found that they contained valuable insights into the resident's thoughts, feelings, and preferences, which were not incorporated into her care plan. The team admitted to gaps in communication that led to the failure to provide appropriate trauma-informed care. The facility's policy on Trauma Informed Care was not followed, resulting in the deficiency identified by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below 5% by not administering the correct dosage of medications per physician's orders for one resident. Specifically, a Licensed Practical Nurse (LPN) administered 400 micrograms of Folic Acid instead of the prescribed 1 mg and 400 mg of Guaifenesin instead of the prescribed 600 mg to a resident with multiple diagnoses, including chronic embolism, thrombosis, acute respiratory failure, bipolar disorder, schizophrenia, anxiety disorder, and thiamine deficiency. The errors were observed during a medication administration session and later confirmed by the LPN and the Director of Nursing (DON). The resident's physician orders were reviewed, and it was acknowledged that the wrong dosages were administered. The facility's policy on administering medications states that medications should be administered in a safe and timely manner as prescribed, and any medication errors should be documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee. Despite these policies, the errors occurred, leading to a medication error rate above the acceptable threshold.
Medication Transfer Error in EMR
Penalty
Summary
The facility failed to effectively use its resources to ensure medications were transferred accurately and completely to the facility's Electronic Medical Records (EMR), leading to a significant medication error for one resident. The resident, who had multiple serious diagnoses including atherosclerosis, embolism, and hypertension, was prescribed Keflex for an infection by his Infectious Disease physician. Upon readmission to the facility, the resident was given Keflex for five days before it was stopped, despite the physician's order for the medication to be continued for 180 days. This resulted in the resident missing 14 doses of the medication over a period of several days. The Director of Nursing (DON) acknowledged that the medication error occurred due to a system update and shift change from 8-hour to 12-hour shifts, which required orders to be updated in the EMR. However, no one reviewed the EMR to ensure all medications were transferred accurately and completely. The DON was not aware of the issue until it was brought to her attention by the Assistant DON. The incident was not reported to the Consultant Pharmacist, the Medical Director was not informed in a timely manner, and the issue was not discussed in any Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting. The facility's Incident Log and Grievance Log did not initially reflect the medication error, and the resident's grievance was not addressed promptly. The Social Services Director (SSD) confirmed that the resident expressed concerns about the missed doses, but the investigation was still ongoing, and the grievance was not initiated when the issue was first identified. The DON admitted that the facility did not follow its policy for administering medications, which required medication errors to be documented, reported, and reviewed by the QAPI committee to inform process changes and additional staff training.
Inaccurate Documentation of IV Dressing Changes
Penalty
Summary
The facility failed to ensure documentation in the medical record was complete and accurate according to accepted professional standards and practices regarding intravenous (IV) dressing change for a resident. The resident had multiple diagnoses, including left above the knee amputation, dysphagia, acute respiratory failure, diabetes type II, gastrostomy, and end-stage renal disease. The physician's order required the IV dressing to be changed every 72 hours and as needed. However, the Treatment Administration Record (TAR) indicated that the IV dressing was signed off as changed every shift, which was not accurate. Nurses acknowledged signing off on the task without actually performing the dressing change, and the order for the IV dressing change was not updated when the resident's peripheral line was replaced with a midline catheter. The Director of Nursing (DON) and other nursing staff confirmed that the documentation was inaccurate and that the IV dressing change order should have been clarified. The DON admitted that she did not know what the nurses were actually signing off on, and the Medical Director stated that he expected accurate documentation in clinical records. The facility did not provide a policy for the accuracy of medical records when requested. This deficiency highlights a significant lapse in maintaining accurate and complete medical records for the resident's IV care.
Failure to Implement Contact Isolation Precautions
Penalty
Summary
The facility failed to implement the physician's order for contact isolation precautions for a resident diagnosed with Extended Spectrum Beta-Lactamase (ESBL) in the urine. Despite the order being placed on 4/18/24, observations on 4/22/24 and 4/23/24 revealed that the appropriate Contact Isolation signage was not posted on the resident's door. Instead, an Enhanced Barrier Precaution sign was in place, which did not meet the requirements for Contact Isolation. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the oversight and confirmed that the correct signage and Personal Protective Equipment (PPE) were not in place as required by the physician's order. The Licensed Practical Nurse (LPN)/Unit Manager on the 100 Unit stated that the resident had previously been on Contact Isolation in March 2024, which was later discontinued and replaced with Enhanced Barrier Precautions. However, the LPN was unaware of the new order dated 4/18/24 for Contact Isolation. The discrepancy between the physician's order and the implemented precautions was identified by the surveyor, highlighting a lapse in the facility's infection prevention and control program.
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What surveyors actually found near you
We read the 209 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare College Park | 2.3 mi | ★★★★★ | 0 | 0 |
| Courtyards Of Orlando Care Center And Rehab | 2.7 mi | ★★★★★ | 5 | 0 |
| Ansley Cove Healthcare And Rehabilitation | 3.4 mi | ★★★★★ | 16 | 3 |
| Rehabilitation Center Of Winter Park | 3.5 mi | ★★★★★ | 0 | 0 |
| Harborview Health Center West Altamonte | 3.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.