Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Edgewater At Waterman Village during CMS and state inspections, most recent first.
A facility failed to ensure accurate MDS coding for three residents. One resident with stroke-related weakness and wheelchair dependence was coded as having no lower-extremity impairment, another resident’s MDS incorrectly showed no rejection of care despite insulin refusals documented on the MAR, and a third resident’s MDS omitted anxiety even though the chart, psych notes, and PRN lorazepam orders documented an anxiety disorder.
Care Plan Missing for Repeated Insulin Refusals: A resident receiving insulin glargine for DM repeatedly refused bedtime insulin, with refusals documented on multiple MAR entries and administration notes showing the resident declined doses when blood glucose was 120 and 72. The resident’s care plan did not address the insulin refusals, and the CM and DON both stated the refusals should have been reflected in the care plan.
The facility failed to properly address pharmacist medication regimen review recommendations for two residents. One resident continued to receive PRN anxiolytics without documented provider rationale when recommendations to discontinue or justify continued use were declined, and another resident’s order to discontinue glimepiride was accepted but the medication remained active and was still administered on the MAR. The DON stated providers decided whether to document a rationale, and an APRN said he did not document the reason for continuing the PRN meds because the resident was seen by psychiatry.
Medication Administered Outside Ordered Parameters: Two residents received meds outside physician-ordered hold parameters. One resident was given Midodrine despite BP readings above the ordered threshold, and another resident received Metoprolol multiple times when pulse was below the ordered hold limit. An RN and an LPN stated they were not aware of or did not recall the parameters, while the physicians expected staff to follow the orders.
Significant insulin medication error due to incorrect sliding scale order. A resident with type II DM had a NovoLog sliding scale order entered incorrectly, and insulin was administered according to that order even though the blood glucose readings did not match the intended scale. The DON and physician identified the order as incorrect and attributed it to a transcription error during admission medication reconciliation, while an LPN stated the insulin was given based on the order in the record.
Unsecured medications and biologicals were found left at the bedside of three residents, including Alka Seltzer, oxymetazoline nasal mist, and 91% isopropyl alcohol. An LPN stated residents were not allowed to have items at bedside and that there were no orders for some of the items, while the DON stated medication should not be left unattended in residents' rooms.
A resident receiving Midodrine for hypotension had the medication administered repeatedly without documented BP readings on the MAR, and progress notes contained no documentation of BP monitoring, hypotension, or Midodrine administration. Staff, including an RN, the DON, and the physician, stated that BP should be obtained and documented before giving BP medications, but the RM said there was no policy for medication parameters and nurses were expected to follow physician orders.
Infection control failures were observed in multiple areas of care. An RN, OT assistant, and CNA provided high-contact care to a resident on EBP without wearing gowns, despite the resident having a midline for IV abt. An LPN also handled a losartan tablet that fell onto the med cart without gloves and administered it to a resident. In the laundry area, doors between soiled and clean linen spaces were left open and clean linens were allowed to touch the floor while being folded.
A resident with chronic kidney disease and prostate cancer did not receive a prescribed Bisacodyl suppository on two occasions. An LPN admitted to not administering the medication due to the resident having a bowel movement, without notifying the physician. The facility's policy requires medications to be administered as ordered, and deviations should be communicated to the physician.
A resident with chronic kidney disease and a history of UTIs did not receive timely laboratory services. Despite a physician's order for a UA C&S, the results indicating a significant bacterial presence were not communicated to the physician. The Infection Preventionist identified the need for antibiotics a day later, but the resident had already been sent to the hospital. The facility's policy to notify the physician promptly was not followed.
A resident's records were found to be incomplete and inaccurate due to a failure to document medication administration. The resident, with conditions including chronic kidney disease and prostate cancer, had orders for specific medications. An LPN admitted to administering the medications but forgot to chart them, contrary to facility policy. The DON confirmed the requirement for proper documentation.
The facility failed to implement care plans for two residents, as their feet were not offloaded while in bed, despite care plans requiring it. Observations showed repeated non-compliance, and staff interviews confirmed the orders for floating heels. The residents' confusion and combativeness were noted as challenges, but the DON acknowledged the need for adherence to care plans.
The facility failed to store medications and biologicals securely, as observed with residents having medications like Biofreeze, Voltaren cream, and eye drops at their bedside. An LPN confirmed that medications should not be left at the bedside, and the DON reiterated this policy. The facility's policy requires medications to be stored securely and locked when not in use.
MDS Assessments Were Not Accurately Coded for Mobility, Medication Refusal, and Anxiety
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents. For a resident with a history of stroke, left-sided weakness, inability to walk, and wheelchair use for mobility, an observation showed a mechanical lift pad under the resident while seated in a wheelchair, and the resident stated she needed a two-person assist for transfers from the mechanical lift to the wheelchair. The resident’s MDS coded Section GG0115, Functional Limitation in Range of Motion, as no impairment for the lower extremities, while the MDS Coordinator stated the resident was impaired on one side of the lower extremities. For another resident, the annual MDS coded Section E0800, Rejection of Care-Presence and Frequency, as behavior not exhibited, even though the MAR showed insulin glargine was refused on two occasions during the lookback period, and a Case Manager stated the MDS needed to be corrected because the resident did refuse insulin. For a third resident, the significant change MDS did not document anxiety disorder under active diagnoses, despite the admission record listing unspecified anxiety disorder, psychology records identifying Other Specified Anxiety Disorder, and a physician order for lorazepam as needed for anxiety; the MDS Coordinator stated the MDS needed to be corrected to document anxiety.
Care Plan Missing for Repeated Insulin Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving insulin glargine for diabetes mellitus. Review of the resident’s progress note showed that on 2/2/2026 the resident refused the bedtime insulin and stated that if the blood glucose was below a certain level, the resident was not taking it. The Medication Administration Record for February 2026 documented multiple refusals of insulin glargine at 9:00 PM on 2/3, 2/6, 2/8, 2/12, 2/13, 2/16, 2/20, 2/22, 2/25, 2/26, and 2/27, and also showed administration on 2/18 with a blood sugar value of 120. The MAR for January 2026 also documented refusal of insulin glargine on 3/6, 3/9, and 3/10, with a separate entry on 3/3 noting refusal when the blood glucose was 72. The resident’s care plan did not include a focus for insulin refusals. During interview, the Case Manager stated the care plan did not include the refusals of insulin and that it should be reflected in the care plan. The DON stated the resident would be expected to be care planned for the refusals. The facility policy stated that a comprehensive care plan shall be developed for each resident with measurable objectives and timetables and should incorporate identified problem areas.
Medication Regimen Review Recommendations Not Properly Documented or Implemented
Penalty
Summary
The facility failed to ensure that monthly medication regimen review recommendations were fully addressed for two residents. For one resident, the consultant pharmacist repeatedly recommended discontinuing PRN anxiolytics without a stop date and documenting the indication, intended duration, and rationale if continued. The physician response on one review stated the recommendation was declined because the medication was PRN only, but later reviews were signed by an APRN with no rationale documented. Progress notes for the resident did not contain physician/provider documentation explaining the continued PRN use of clonazepam or lorazepam during the reviewed periods. For another resident, the consultant pharmacist recommended discontinuing glimepiride because the resident received insulin and a sulfonylurea together. The physician accepted the recommendation and wrote to discontinue glimepiride, but the medication remained on the active order list. The resident’s MAR showed glimepiride continued to be administered throughout February and March 2026 despite the documented order to discontinue it. During interviews, the DON stated it was up to providers whether they replied or entered a rationale when pharmacist recommendations were presented. The physician stated he kept the resident on PRN lorazepam because it was needed for agitation in addition to scheduled doses, and the APRN stated he did not document the rationale for continuing PRN lorazepam and clonazepam because the resident was being seen by a psychiatric provider. The facility policy required the consultant pharmacist to review each resident’s medication regimen at least monthly and to identify medication or documentation errors.
Medication Administered Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications for 2 of 9 residents reviewed for medication management. For one resident, the physician ordered Midodrine HCl 10 mg every 8 hours for hypotension with instructions to hold for systolic blood pressure greater than 100, but the MAR showed the medication was administered multiple times when the resident's blood pressure was above that parameter, including readings such as 105/63, 127/78, 116/72, 123/64, 108/63, 109/68, and 110/62. During interview, the RN stated she administered the medication and was not aware of the parameters associated with the order, and the physician stated he expected nursing staff to follow his orders. For another resident, the physician ordered Metoprolol Succinate ER 25 mg every 12 hours for hypertension with instructions to hold for systolic blood pressure less than 120, diastolic blood pressure less than 50, or pulse less than 60. The MAR showed the medication was administered on multiple occasions when the pulse was below 60, including pulse rates of 59, 57, 58, 54, 57, 56, 51, 59, 58, and 55, and once when systolic blood pressure was 115. An LPN stated she did not recall the resident having parameters for metoprolol and acknowledged the medication should not have been administered when the heart rate was less than 60. The DON stated nursing staff should check vital signs and not administer medication when it is outside ordered parameters, and the physician stated he expected nurses to follow all parameters.
Significant insulin medication error due to incorrect sliding scale order
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for one resident reviewed for medication management. Resident #123 had a physician order dated 3/7/2026 for NovoLog FlexPen insulin with a sliding scale that directed 2 units for a blood glucose of 1-150, 4 units for 200-249, 6 units for 250-299, 8 units for 300-349, and 10 units for 350-400, to be given subcutaneously three times a day for type II diabetes mellitus. The MAR for March 2026 showed that 2 units of insulin were administered on 3/9/2026 at 9:00 AM for a blood glucose reading of 62 and again at 1:00 PM for a blood glucose reading of 122. During interview, the DON stated the sliding scale was not the typical one used at the facility and said she would contact the physician to verify the order. After reviewing the order with Physician #3, the DON stated the sliding scale was incorrect and should have started at 150 rather than 1. Physician #3 stated the incorrect sliding scale was likely the result of a transcription error during the admission medication reconciliation process. Staff C stated the insulin was administered according to the sliding scale order in the record, and Staff D stated the order was entered into the electronic medical record and was likely entered incorrectly during transcription.
Unsecured medications and biologicals left at residents' bedsides
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in one of two halls when multiple residents had medication or related products left unattended in their rooms. During an observation on 3/9/2026, one box of Alka Seltzer was found on top of Resident #64's bedside table while the resident was not in the room. Staff F, LPN, stated that Resident #64 was not known to be able to self-administer medications, and later removed the Alka Seltzer from the room. Also on 3/9/2026, Resident #62 had a bottle of oxymetazoline HCl nasal decongestant on top of her bedside table while sitting in her room. Resident #62 stated she would administer the nasal mist herself and that the doctor said she could have it, but Staff G, LPN, stated the nasal mist was not something she brought to the resident and that residents were not allowed to have anything at bedside; Staff G then removed the nasal mist. In a separate observation, Resident #15 had a bottle of 91% isopropyl alcohol on top of the nightstand and stated she used it on her skin. Staff G stated there was no order for it and removed the bottle from the room. The DON later stated medication should not be left unattended in residents' rooms and that residents able to self-administer would be provided locked boxes to store medication.
Incomplete BP Documentation for Midodrine Administration
Penalty
Summary
Medical records were not maintained in accordance with accepted professional standards for one resident receiving Midodrine HCl for hypotension. The physician order directed that Midodrine HCl 5 mg be given three times daily and held if systolic blood pressure was above 130, but the resident’s MAR showed the medication was administered repeatedly without any blood pressure documented before administration across December 2025, January 2026, February 2026, and March 2026. Review of the resident’s progress notes from 12/1/2025 through 3/9/2026 also showed no documentation regarding blood pressure monitoring, hypotension, or the administration of Midodrine. During interviews, Staff A, RN, stated that blood pressure was expected to be checked before administering Midodrine and documented, and confirmed that blood pressures were not being documented for the resident. The DON stated that blood pressure was to be obtained and documented before giving blood pressure medications. Physician #1 stated that blood pressure medications, including Midodrine, were to have blood pressure taken before administration. The RM stated there was no policy regarding parameters for medication administration and that nurses were expected to follow physician orders for vital signs or stated parameters.
Infection Control Failures in PPE Use, Medication Handling, and Laundry Practices
Penalty
Summary
The facility failed to ensure staff used appropriate PPE during enhanced barrier precautions for a resident with a midline for IV antibiotics. During an observation, the RN unit manager entered the resident’s room, performed hand hygiene, donned gloves, but did not wear a gown while flushing the IV needleless connector, connecting IV tubing, and starting the IV infusion. An occupational therapy assistant and a CNA were also in the room assisting with repositioning the resident in bed and were wearing gloves but no gowns. The RN unit manager stated that a gown should have been donned, and the occupational therapy assistant stated that she had forgotten the resident was on enhanced barrier precautions. The resident’s care plan identified the resident as being on enhanced barrier precautions because of the midline for IV antibiotics, and the facility policy required gown and glove use for high-contact care activities, including device care or use. The facility also failed to ensure infection control procedures were followed during medication administration for a resident receiving losartan 25 mg daily for hypertension. During observation, an LPN poured the medication, and when a tablet fell from the blister pack onto the top of the medication cart, the LPN picked it up without wearing gloves and placed it into the medication cup before administering it to the resident. The LPN stated the medication should have been discarded and replaced, and that medication should not be touched without gloves. The DON stated the medication should have been discarded when it fell onto the cart and not administered to the resident. The facility’s medication administration policy required appropriate infection control procedures, including hand washing, antiseptic technique, and gloves. The facility also failed to maintain infection control practices in the laundry area. During a tour, the door between the soiled linen room and the clean linen room was propped open despite signs on both sides stating to keep doors closed at all times. Staff stated the door should have been closed, and management confirmed it should remain closed. During the same tour, two laundry aides were folding clean resident bed linens without using the folding table and were holding the sheets in the air so that several inches of the clean sheets rested on the floor while being folded. The Operations Manager stated clean linens were not to touch the ground because they would then be considered contaminated or soiled, and the DON stated the entry door, exit door, and door between the soiled and clean laundry areas were to remain closed to minimize contamination and maintain infection control standards.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered, which is a deficiency in providing care according to professional standards of practice. The resident, who was admitted with diagnoses including Stage 3 chronic kidney disease and malignant neoplasm of the prostate, had a physician's order for a Bisacodyl rectal suppository to be administered at bedtime for constipation. However, the Medication Administration Record for October 2024 showed no documentation of the suppository being administered on two specific dates. During interviews, a Licensed Practical Nurse admitted to not administering the suppository because the resident had a bowel movement, acknowledging that the medication should have been given routinely as per the order. The nurse did not notify the physician of the deviation from the order. The Advance Practice Registered Nurse confirmed that physician orders should be followed unless the resident refuses, in which case the refusal should be documented and the physician notified. The Director of Nursing also stated that the suppository should have been administered as ordered, and if not, the physician should have been informed. The facility's policy on administering medications emphasizes that medications must be administered as prescribed by the attending physician.
Failure to Communicate Lab Results Timely
Penalty
Summary
The facility failed to provide timely laboratory services to meet the needs of a resident with chronic kidney disease and a history of UTIs. The resident was admitted with a physician's order for a CBC, CMP, and UA C&S. The UA C&S results, which indicated a significant bacterial presence, were collected and reported but not communicated to the physician. The Infection Preventionist reviewed the results a day after they were reported and sent an email to the interdisciplinary team indicating the need for antibiotic therapy. However, by that time, the resident had already been sent to the hospital. Interviews revealed that the nurse assigned to the resident was responsible for following up on abnormal lab results during their shift, but the results were not communicated to the physician. The Director of Nursing confirmed that the urinalysis and culture sensitivity report was positive and not reported to the physician. The facility's policy required the attending physician to be promptly notified of test results, but this procedure was not followed, leading to a delay in the resident receiving necessary treatment.
Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for one of the residents reviewed. The resident in question was admitted with diagnoses including Stage 3 chronic kidney disease and malignant neoplasm of the prostate. The resident had physician orders for Prostat AWC to be administered every shift for wounds, Senna S for constipation, and Carbidopa-Levodopa for Parkinson's. However, the Medication Administration Record (MAR) for October 2024 showed no documentation of the administration of these medications on the night shift of October 7, 2024. During a telephonic interview, a Licensed Practical Nurse (LPN) admitted to administering the medications on the specified date but forgot to document them. The Director of Nursing confirmed that medications should be given as ordered and documented in the resident's chart. The facility's policy on administering medications requires the individual administering the medication to initial the MAR on the appropriate line and date before administering the next resident's medication. Additionally, the facility's policy on medical record documentation mandates that all treatments and medications ordered by the physician be documented on the resident's MAR/TAR.
Failure to Implement Care Plans for Offloading Feet
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, specifically regarding the offloading of their feet while in bed. Observations over two days revealed that both residents were consistently found with their feet not offloaded, despite their care plans explicitly stating the need to float heels when in bed. This was observed multiple times for each resident, indicating a lack of adherence to the care plans designed to meet their specific needs. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the residents had orders for floating heels. However, the LPN noted that both residents were hard to follow commands due to confusion and combativeness, which may have contributed to the failure in implementing the care plans. Despite these challenges, the Director of Nursing acknowledged that if a resident is care planned for offloading, it should be done, highlighting a gap between the care plan requirements and actual practice.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as observed during a survey. On one occasion, a resident was found with a bottle of Biofreeze pain relief gel on her nightstand, which she stated was used for arthritis relief. Another resident had multiple medications, including Biofreeze, Voltaren cream, and Lotrimin Clotrimazole cream, on her bedside table. The resident mentioned using these for muscle relaxation and neck pain. A Licensed Practical Nurse (LPN) acknowledged that sometimes families bring in medications without the staff's knowledge, and confirmed that medications should not be left at the bedside. Additionally, a third resident was found with two bottles of eye drops in her cabinet, which she could not reach and was unsure of their purpose. The following day, only one bottle remained, and the LPN confirmed that there were no orders for eye drops for this resident. The Director of Nursing reiterated that medications should not be left at the bedside. The facility's policy on medication storage mandates that medications and biologicals be stored securely and locked when not in use, which was not adhered to in these instances.
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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 Mount Dora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante At Mt Dora, Inc | 2 mi | ★★★★★ | 11 | 0 |
| Ruleme Center | 2.7 mi | ★★★★★ | 9 | 0 |
| Bayview Center | 3.1 mi | ★★★★★ | 7 | 0 |
| Lake Eustis Healthcare And Rehabilitation Center | 3.2 mi | ★★★★★ | 10 | 2 |
| Solaris Healthcare Waterman | 3.9 mi | ★★★★★ | 1 | 0 |
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