Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Harborview Health Center West Altamonte during CMS and state inspections, most recent first.
The facility failed to implement and document an effective QAPI program, as required by its policy. The NHA reported having no participation in QAPI meetings, and the DON, in place since the prior year, acknowledged concerns with lack of notification of changes in condition, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that omitted respiratory care, and incomplete or inaccurate medical records, with no active PIPs addressing these issues. Review of QAPI records showed multiple PIPs initiated for change‑in‑condition notification, risk management events, documentation, and care plans, including one started after a resident’s representative was not informed of a hospital transfer following cardiac arrest, but none had supporting documentation, end dates, or evidence of monitoring or evaluation.
Two residents experienced significant changes in condition without timely notification to their representatives and, in one case, the physician. One cognitively impaired resident with multiple serious diagnoses suffered a cardiac arrest; staff initiated CPR, called 911, and transferred her to the hospital, but documentation showed only the resident herself was listed as notified, and her healthcare proxy later reported she was never contacted by the facility and learned of the event from the hospital. Another cognitively intact respite resident developed skin tears to the arm and leg, reportedly related to an outing incident, which were documented on CNA task lists but not reflected in nursing progress notes or the discharge summary; his daughter discovered a bandage at pickup and stated she was never informed of the incident or injuries despite attempts to reach facility leadership. The DON acknowledged that a change in condition should have been documented and that the nurse, MD, and family should have been notified, contrary to the facility’s own change-in-condition policy.
Two residents with significant respiratory conditions, including acute and chronic respiratory failure, COPD, CHF, and documented oxygen dependency, were admitted and readmitted with orders for continuous or PRN oxygen and multiple respiratory treatments, yet their baseline care plans did not address respiratory status, oxygen therapy, or individualized interventions such as head-of-bed elevation, monitoring, or reminders not to remove oxygen devices. One cognitively impaired resident’s family member reported finding the resident without a nasal cannula and with the bed flat despite continuous oxygen needs and stated she never received a copy of the initial plan of care or met with staff about respiratory concerns. Facility leadership confirmed that baseline care plans were incomplete, lacked respiratory focuses and interventions, and that policy required development of a comprehensive baseline care plan within 48 hours of admission and provision of a written summary to the resident or representative.
A resident with end stage liver disease, hepatocellular carcinoma, CHF, COPD, diabetes, and hypertension required oxygen therapy per physician and pulmonary specialist orders, including specific LPM ranges and directions to maintain SpO2 above 92% and use oxygen at night. Facility records showed ongoing oxygen use and weekly tubing changes, but no corresponding comprehensive care plan for oxygen therapy was developed. The resident was observed on oxygen via nasal cannula at 5 LPM, above the ordered 2–4 LPM PRN, and an RN reported that the resident or her son sometimes adjusted the flow rate. The DON and MDS Coordinator both confirmed the absence of an oxygen care plan despite daily order review and a policy requiring care plans for all services identified in the comprehensive assessment.
Two residents experienced incomplete and inconsistent clinical documentation related to significant changes in condition and skin injuries. One resident with multiple serious comorbidities had a code blue event where staff accounts conflicted regarding who found the resident, the resident’s condition before becoming unresponsive, who was present during CPR, and who made emergency calls; the medical record lacked key details such as time of event, condition prior to arrest, and identity of the person who found the resident. Another resident admitted for respite care with a history of stroke and a heel pressure ulcer reportedly sustained arm and leg injuries during an outing, as described by the resident and his daughter, while CNA notes later recorded skin tears to the arm and leg as “not new,” but there was no corresponding nursing assessment, change-in-condition documentation, provider or family notification, wound identification, treatment orders, or wound treatments recorded, and the discharge summary stated there were no skin issues.
A resident with cognitive intactness and physical impairments suffered second-degree burns after a CNA improperly microwaved noodles, leading to a spill. The facility lacked a clear policy and staff education on food reheating, contributing to the incident. The resident was transferred to a specialized burn unit for treatment.
A resident suffered second-degree burns after hot soup spilled on her, and the facility failed to conduct a thorough assessment and provide timely treatment. The LPN only noted a skin tear and did not perform a head-to-toe assessment, missing burns on the resident's arm, abdomen, and thigh. The resident was later hospitalized for five days. Additionally, another resident's pressure wound treatment lacked a physician's order and proper documentation.
A resident with hemiplegia and diabetic neuropathy suffered burns after a CNA reheated noodles in a microwave, contrary to facility policy. The facility lacked specific guidance and training for staff on reheating food, and no thermometers were available to check food temperatures. The incident highlighted a communication gap between the administrative team and staff regarding food safety procedures.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing while feeding residents and using the term 'feeders.' One resident was left to eat with her hands until her daughter intervened, despite previous concerns raised. Staff admitted to being in a hurry and using inappropriate language, contrary to facility policy.
The facility failed to complete and update PASARR Level I evaluations for two residents. One resident was readmitted with multiple diagnoses, including mental health conditions, but the PASARR did not list any mental illness. Another resident's PASARR was outdated and inaccurate, not reflecting current mental illness diagnoses despite evident behaviors and conditions. The DON acknowledged the oversight and lack of communication in ensuring PASARRs were completed and updated as per facility policy.
A resident with multiple health issues, including an unhealed pressure ulcer, did not receive weekly skin sweeps as ordered by the physician. Despite signatures on the MAR indicating acknowledgment of the order, documentation showed that skin sweeps were only conducted twice. Interviews with staff revealed inconsistencies in the execution and documentation of the skin sweeps, leading to a deficiency in care.
A resident with COPD was not provided respiratory therapy as per physician orders, with the oxygen concentrator set incorrectly and the nasal cannula not in use. The LPN mistakenly believed the order was for as-needed oxygen, leading to a lapse in care. The Unit Manager and DON confirmed the expectation for nurses to verify orders each shift.
A resident with multiple pressure ulcers received wound care without proper infection control practices. The Wound Care nurse performed the procedure alone, despite the resident's inability to reposition herself, leading to potential cross-contamination. The ADON confirmed that proper assistance should have been ensured to prevent infection.
Two residents were found with inaccessible call devices, preventing them from calling for staff assistance. One resident's call device was placed on a nightstand out of reach, while another's was tangled in the bed frame. CNAs later repositioned the devices within reach, aligning with the facility's policy for call light accessibility.
Two residents in an LTC facility did not receive showers as scheduled or according to their preferences. One resident, with severe cognitive impairment, only received two showers over three months, with no documentation of refusals. Another resident, with moderate cognitive impairment, had a grievance filed for morning showers but continued to receive them in the evening. The facility's policy on person-centered care was not followed, leading to deficiencies.
Failure to Implement and Document an Effective QAPI Program
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective, comprehensive, data‑driven Quality Assurance and Performance Improvement (QAPI) program as required by its own policy. During an interview, the Nursing Home Administrator (NHA), who had been in the role for only two days, reported he had not participated in any QAPI meetings. The DON, who had been in her role since June 2025, acknowledged concerns related to lack of notification of changes in condition for residents, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that did not include respiratory care, and incomplete or inaccurate medical records. She stated she was not aware of these concerns and that there were no active Performance Improvement Plans (PIPs) addressing them, despite the facility’s process of bringing departmental concerns from morning clinical meetings to monthly QAPI meetings for discussion and PIP development. Record review showed that several PIPs had been initiated in 2025 without supporting documentation, end dates, or evidence of monitoring. A PIP started in January 2025 for notification of changes in condition followed an incident in which a resident’s representative was not informed that the resident had been transferred to the hospital after a cardiac arrest, but there was no documentation of what actions were taken or how they were monitored. Additional PIPs were noted for risk management events in April 2025, documentation in September 2025, and care plans and baseline care plans in June 2025, all lacking corresponding documentation of implementation or evaluation. This was confirmed by the NHA. Review of the facility’s QAPI policy, revised in August 2025, showed that the facility was required to maintain documentation demonstrating an ongoing QAPI program, including data collection and analysis, and documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities, which was not reflected in the records reviewed.
Failure to Notify Representatives and Physicians of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify residents’ representatives and physicians of significant changes in condition for two residents. For the first resident, an elderly woman with severe cognitive impairment and multiple serious diagnoses including metabolic encephalopathy, dysphagia, diabetes, sepsis, congestive heart failure, acute kidney failure, adult failure to thrive, COVID-19, pneumonia, and acute respiratory failure, the record showed she required a surrogate for decision-making. On the identified date, she was found unresponsive and in cardiac arrest. Staff initiated CPR, called 911, obtained a physician’s order to transfer her to the emergency room, and completed a transfer and discharge form. However, the form listed the resident herself as the responsible party notified, using her own phone number, and there was no documentation that any emergency contacts or her healthcare proxy were notified of this critical change in condition and transfer. Interviews further clarified the lack of appropriate notification for this resident. An RN who assisted with CPR stated that during the code, the Nurse Supervisor was at the desk calling 911, the physician, and the family, and later the former DON informed the nurses that the resident’s daughter was upset because she had not been notified of her mother’s transfer. The daughter, identified in the record as the healthcare proxy and listed as emergency contact #1, reported she was not contacted by the facility and only learned of her mother’s cardiac arrest and transfer when the hospital called her later that evening. She stated she told the former DON she was upset about not being notified and was told that staff had mixed up the phone numbers, but she never received an explanation or follow-up. The former DON confirmed that the assigned nurse reported confusing the phone numbers and acknowledged that no investigation was conducted after the incident, and that the family was only made aware of the transfer when the granddaughter called the facility after the resident had already been transferred. The second resident was admitted for respite care with diagnoses including stroke with right-sided deficit, a right heel pressure ulcer, coronary artery disease, and a pacemaker, and was documented as cognitively intact. Initial assessments and daily nursing documentation indicated no skin issues, while CNA task lists later documented a skin tear to the arm and then a skin tear to the leg on subsequent days. The physician’s history and physical noted right heel pain but did not mention arm or leg skin tears, and the discharge summary stated there were no skin issues at discharge. The resident’s daughter reported that when she arrived to pick him up, she observed a bandage on his leg and was told by the resident that wheelchairs had fallen during an outing, causing scratches to his arm and a gash to his leg. She stated that no one from the facility had called to inform her of the incident or the resulting skin impairments, despite her multiple calls to the Administrator and a conversation with the Social Worker. The DON later stated there should have been a documented change in condition for the skin tears and confirmed that the nurse, physician, and daughter should have been notified. The facility’s policy on Change in a Resident’s Condition or Status required prompt notification of the resident, attending physician, and representative of changes in medical or mental condition or status, including incidents, accidents, injuries, and transfers, which was not followed in these cases.
Failure to Implement Respiratory-Focused Baseline Care Plans and Provide Plan Summaries
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement effective, person-centered baseline care plans within 48 hours of admission for residents with significant respiratory needs, and failure to provide a required written summary of the baseline care plan to a resident’s representative. For one resident with severe cognitive impairment, acute respiratory failure, COVID-19, pneumonia, CHF exacerbation, and continuous oxygen orders, the baseline care plan created at readmission did not address respiratory needs or continuous oxygen therapy. The plan was largely blank except for behavior and diet comments, and did not include individualized interventions such as maintaining the head of bed elevation or reminders not to remove the nasal cannula, despite these needs being documented in transfer forms and physician orders. The same resident’s daughter reported that the resident required continuous oxygen, preferred to have the head of bed elevated to breathe better, and needed reminders not to remove her nasal cannula due to confusion. She stated that on several visits she found the resident without the nasal cannula and with the head of the bed flat, and that staff were not consistently communicating about the resident’s preferences and comfort needs. The daughter also confirmed she never received a copy of the initial plan of care and had not met with anyone at the facility regarding her concerns about her mother’s respiratory status, contrary to facility policy requiring that a written summary of the baseline care plan be provided to and signed by the resident or representative. For a second resident with a history of end stage renal disease on dialysis, cardiac arrest, CHF, acute and chronic respiratory failure, COPD, colostomy, and hypertension, hospital records documented chronic respiratory failure and oxygen dependency, and the resident returned with a primary diagnosis of acute respiratory failure. Physician orders included three respiratory inhalers, and nursing notes and vital signs documented oxygen use on multiple dates. However, both the admission and readmission baseline care plans did not address the resident’s respiratory status, respiratory medical conditions, or chronic oxygen use. The MDS Director and DON acknowledged that respiratory assessments, care plan focuses, and interventions such as oxygen use, monitoring, head of bed elevation, and observation for respiratory distress should have been included, and that the baseline care plan form, even before modification, allowed for documentation of such needs.
Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing oxygen use for a resident who required oxygen therapy. The resident was admitted with multiple diagnoses including end stage liver disease, hepatocellular carcinoma, diastolic congestive heart disease, COPD, diabetes, and hypertension. An admission MDS showed the resident required oxygen therapy, was cognitively intact with a BIMS score of 15/15, and needed full assistance with toileting, hygiene, and transfers. Physician orders documented oxygen use beginning with 2 LPM as needed, then 1 LPM, and later 2–4 LPM as needed to maintain oxygen saturation greater than 92%. Pulmonary physician progress notes further directed staff to monitor oxygen saturation, titrate oxygen as needed, and provide supplemental oxygen as needed to maintain saturation above 92% and at night while sleeping. The Treatment Administration Record showed weekly oxygen tubing changes starting in late December, and nursing documentation recorded ongoing oxygen use at various flow rates. Despite these documented needs and orders, review of the resident’s care plan revealed there was no care plan for oxygen use. On observation, the resident was found in bed wearing a nasal cannula connected to an oxygen concentrator set at 5 LPM, although the current order was for 2–4 LPM as needed. The resident reported using oxygen due to shortness of breath, liver cirrhosis with frequent fluid removal from the abdomen, COPD, and fatigue limiting her mobility. An RN confirmed the concentrator was set at 5 LPM, acknowledged the order was for 2–4 LPM as needed, and stated that the resident or her son sometimes changed the oxygen rate. The DON confirmed the resident used oxygen per physician orders and acknowledged there was no oxygen care plan but that there should have been one. The MDS Coordinator, who reviewed physician orders daily, also confirmed there was no care plan for oxygen use and stated that the orders must have been missed, despite the facility’s policy requiring a comprehensive person-centered care plan including all services identified in the comprehensive assessment.
Incomplete and Inconsistent Clinical Documentation for Change in Condition and Skin Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and consistent clinical records for two residents, affecting the reliability of the medical record and continuity of care. For the first resident, who had multiple serious diagnoses including metabolic encephalopathy, dysphagia, diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive, staff accounts of a code blue event were inconsistent and incompletely documented. An LPN working the night shift reported being told that an unidentified CNA found the resident unresponsive, that this was reported to the second-shift Nurse Supervisor, and that EMS transported the resident to the hospital. An RN who participated in the code stated she heard the assigned nurse calling for help, found the resident unresponsive with the assigned nurse performing CPR, and reported that only she and the assigned nurse were in the room while the Nurse Supervisor made calls to 911, the family, and the physician. The former DON later reported being informed of the code blue the next morning and recounted a different version from the assigned nurse, stating the nurse had gone in to check the resident’s blood sugar, found the resident with Cheyne-Stokes breathing, stayed at the bedside until the resident became unresponsive, and then called a code blue. In this account, the second-shift Nurse Supervisor was the only other person in the room during CPR, and the assigned nurse made the calls to 911, the physician, and the family. Review of the resident’s medical record showed a change in condition note indicating the resident was found unresponsive and had a cardiac arrest, that CPR was initiated, 911 was called, and a transfer to the emergency room was ordered. However, the documentation lacked a specific time of the event, did not identify who found the resident, and did not describe the resident’s condition prior to becoming unresponsive, contrary to the facility’s documentation policy requiring a complete and accurate representation of the resident’s experiences. For the second resident, admitted for respite care with a history including stroke with right-sided deficit, right heel pressure ulcer, coronary artery disease, and a pacemaker, the facility failed to document an incident and resulting skin impairments. The resident’s daughter reported that when she arrived to pick him up at discharge, she observed a bandage on his leg and was told by the resident that he had gone on an outing where unsecured wheelchairs fell on the way back, scratching his arm and causing a gash in his leg; she stated no one from the facility informed her of these new wounds or the incident. CNA documentation showed the resident refused group activities on two specific dates and contained skin observation entries noting a “not new” skin tear to the arm on one date and a “not new” skin tear to the leg on another, with no skin observation documentation for several intervening days. The treatment administration record and physician orders contained no wound identification or treatment orders for the relevant period, and progress notes and admission assessments documented skin as fair, warm, and dry, with no skin issues noted. There was no documentation of a change in condition, no nursing assessment of the reported wounds, no provider or family notification, and the discharge summary stated there were no skin issues at discharge, despite the CNA skin observation entries and the daughter’s report of a leg wound with a bandage.
Resident Suffers Burns Due to Improper Food Handling
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who suffered second-degree burns due to the improper handling of microwaved food. The incident involved a resident with left-sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand. The resident was cognitively intact and required setup assistance for eating. On the day of the incident, a CNA prepared a cup of noodles for the resident using a microwave, which was not in accordance with the facility's policy that required food to be heated in the kitchen. The hot liquid from the noodles spilled on the resident, causing burns to her left arm, hand, abdomen, and thigh. The facility lacked a clear policy and staff education regarding the heating and reheating of resident food, which contributed to the incident. The CNA who prepared the noodles was unaware of any in-service training related to food reheating, and the facility's administration had not ensured that all staff were educated on this matter. The Administrator acknowledged that microwaves should not have been available on the unit and that there was a previous discussion about reheating food due to a grievance, but no formal education was provided to the staff. Following the incident, the resident's daughter called 911, and the resident was transferred to a hospital and then to a specialized burn unit. The facility's documentation and response to the incident were inadequate, as the resident's wet clothes were not removed promptly, and there was a lack of thorough assessment and documentation by the nursing staff. The facility's failure to implement and educate staff on proper food handling procedures resulted in actual harm to the resident.
Failure to Provide Timely Burn Assessment and Treatment
Penalty
Summary
The facility failed to provide immediate and thorough nursing assessment and treatment services related to burns for a resident, resulting in actual harm. The resident, who had left-sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand, suffered second-degree burns after hot noodle soup spilled on her. The incident occurred when a CNA heated the soup in a microwave and placed it on the resident's table, leading to the spill. The LPN who assessed the resident only noted a skin tear on the left hand and did not perform a comprehensive head-to-toe assessment, missing burns on the resident's left arm, abdomen, and thigh. The resident's daughter was informed of the incident and upon arrival at the facility, found her mother in pain and still in wet clothes. The daughter called 911, and the resident was taken to a hospital where she was assessed and subsequently transferred to a specialized burn unit. The hospital records indicated partial thickness burn wounds with blistering on multiple areas of the resident's body. The facility's failure to conduct a complete assessment and provide timely treatment led to the resident being hospitalized for five days. Additionally, the facility failed to obtain a physician's order for treatment and date a treatment dressing for another resident with a pressure wound. An undated treatment bandage was observed on the resident's right forearm, and upon review, it was found that there was no physician's order for the treatment. The facility's policy required evidence-based treatments in accordance with physician orders, which was not followed in this case.
Lack of Food Reheating Policy Leads to Resident Burns
Penalty
Summary
The facility failed to provide a policy or training to staff regarding the reheating of food for residents, which resulted in a resident receiving second-degree burns. The incident involved a resident with left-sided hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand. The resident requested a cup of noodles from the facility's Activity Store, which a CNA heated in a microwave located in the staff kitchen on the unit. As the CNA placed the noodles on the resident's over-bed tray table, the resident accidentally knocked the cup, causing the hot noodles to spill and burn her. Interviews with staff and a review of facility policies revealed that there was no specific guidance or training provided to staff on the safe reheating of food for residents. The Administrator and former DON acknowledged that there was a discussion about not heating or reheating resident food, but it was only discussed with the Administrative team and not communicated to the staff. Additionally, there were no thermometers available in the unit kitchens for staff to check food temperatures, and the staff did not receive any education on this matter until after the incident occurred.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat residents with dignity and care, as evidenced by staff standing while feeding residents and referring to them as 'feeders.' On one occasion, a CNA was observed standing over a resident while feeding her, acknowledging that she was aware of the importance of sitting at eye level but was too busy to get a chair. Additionally, the same resident was left unattended with her meal tray, leading her to eat with her hands until her daughter arrived to assist. The daughter expressed concerns about the lack of assistance her mother received during meals, despite having previously raised these issues with the facility. Another incident involved a CNA standing while feeding a different resident, citing being in a hurry as the reason. The CNA admitted to using the term 'feeder' aloud in the hallway to identify residents needing meal assistance. The facility's policy emphasized the importance of treating residents with dignity, including using respectful language and ensuring staff are informed about residents' needs. The DON and Unit Manager confirmed that staff should not use the term 'feeder' and should be familiar with residents' needs before delivering meal trays.
Failure to Complete and Update PASARR Evaluations
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed for two residents. Resident #33 was readmitted to the facility from the hospital with multiple diagnoses, including cerebral infarction, aphasia, vascular dementia, major depressive disorder, and mood disorder. Despite these conditions, the PASARR Level I evaluation dated 10/25/23 did not list any mental illness diagnoses. The Director of Nursing (DON) acknowledged that a new PASARR should have been completed upon the resident's readmission, but it was not done due to a lack of communication between the Admissions office and the DON. Resident #65 was admitted with diagnoses including chronic atrial fibrillation, type 2 diabetes, dementia, major depressive disorder, and mood disorder. The resident's PASARR Level I screen dated 5/23/22 was found to be inaccurate as it did not list any mental illness diagnoses, despite the resident's care plan and medical records indicating behaviors and conditions associated with mental illness. The DON and Assistant DON confirmed the PASARR was inaccurate and had not been updated to reflect the resident's current diagnoses. The facility's policy required PASARR Level I to be completed prior to admission and updated if new diagnoses arose, which was not adhered to in these cases.
Failure to Conduct and Document Weekly Skin Sweeps
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent pressure ulcers for a resident. The resident, a male with multiple diagnoses including heart failure, diabetes, and prostate cancer, was at risk for pressure ulcers and had an unhealed pressure ulcer classified as an unstageable deep tissue injury. A physician's order required weekly skin sweeps to be conducted every Wednesday on the 7 AM-3 PM shift. However, documentation revealed that skin sweeps were only conducted on two occasions, and no other documentation could be identified to confirm that the weekly skin sweeps were performed as ordered. Interviews with facility staff, including an LPN, the Unit Manager, the Assistant Director of Nursing, and a Registered Nurse, revealed inconsistencies in the documentation and execution of the skin sweeps. The staff acknowledged the lack of documentation for the skin sweeps despite signatures on the Medication Administration Record (MAR) indicating acknowledgment of the order. The facility's policy required a full body skin assessment upon admission and weekly thereafter, but the failure to document and perform the weekly skin sweeps as ordered led to the deficiency.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory therapy as per physician orders for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions. The resident was observed without the prescribed nasal cannula for oxygen, and the oxygen concentrator was set at 1.5 liters per minute instead of the ordered 1 liter per minute. The resident stated she rarely used the oxygen, and the assigned nurse, LPN F, incorrectly believed the order was for oxygen as needed. Upon verification, LPN F acknowledged the error and corrected the oxygen flow rate. The Unit Manager and Director of Nursing confirmed that the expectation was for nurses to check and verify oxygen orders on all shifts. The facility's Oxygen Administration Policy required oxygen to be administered under physician orders, except in emergencies. The failure to follow the physician's orders for continuous oxygen at the correct flow rate was acknowledged by the nursing staff, indicating a lapse in adherence to the established protocol.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with multiple pressure ulcers. The resident, who was readmitted from the hospital with conditions including cerebral infarction, vascular dementia, and multiple pressure ulcers, was observed receiving wound care on the right buttock. The Wound Care nurse performed the procedure without a second person to assist, despite the resident's inability to reposition herself due to severe cognitive impairment and limited mobility. The nurse attempted to maintain a clean environment but acknowledged the difficulty in doing so without assistance. The Assistant Director of Nursing, who also serves as the Infection Preventionist, confirmed that the Wound Care nurse should have ensured proper assistance was available to prevent cross-contamination. The facility's policy on clean dressing changes emphasizes the importance of preventing infection and cross-contamination, which was not fully adhered to in this instance. The nurse's actions, including handling the resident and wound supplies without a second person, contributed to the deficiency in infection control practices.
Inaccessible Call Devices for Residents
Penalty
Summary
The facility failed to provide accessible call devices for two residents, leading to a deficiency in ensuring residents could call for staff assistance. Resident #30, who was alert and oriented, was observed with a call device placed on a nightstand out of her reach. She expressed a desire to get out of bed and into her wheelchair but had no means to contact staff for help. A CNA later confirmed the inaccessibility of the call device and repositioned it within the resident's reach, educating her on its use. Similarly, Resident #55, also alert and oriented, had a call bell device that was wound up in the bed frame and out of reach. The resident attempted to use the call bell but was unable to reach it. A CNA verified the issue and adjusted the call light to be within the resident's reach. The facility's policy requires call lights to be within hand's reach for all residents, and the DON emphasized the availability of special call lights for residents with difficulty using standard devices.
Failure to Provide Scheduled Showers and Honor Resident Preferences
Penalty
Summary
The facility failed to provide scheduled showers and accommodate resident preferences for two dependent residents. Resident #1, a 72-year-old male with severe cognitive impairment and multiple health conditions, was scheduled for showers twice a week but only received them twice over a three-month period. There was no documentation of shower refusals or adjustments to his care plan to reflect any changes in preference. The Director of Nursing acknowledged the lack of documentation and confirmed that showers were not provided as scheduled. Resident #5, an 82-year-old female with moderate cognitive impairment and other health issues, was also not provided showers according to her preference. Despite a grievance filed by her responsible party requesting morning showers, the resident continued to receive showers in the evening. Documentation showed inconsistencies, with some showers not recorded in the Point of Care system. The Assistant Director of Nursing could not explain the discrepancies, and the Unit Manager confirmed awareness of the grievance but noted that the resident's preferences were not honored. The facility's policy on Activities of Daily Living emphasizes person-centered care and honoring resident preferences, yet this was not adhered to in the cases of Residents #1 and #5. The lack of proper documentation and failure to accommodate resident preferences led to the identified deficiencies in care.
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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 Altamonte Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Forest Lake | 2.1 mi | ★★★★★ | 0 | 0 |
| Village On The Green | 2.7 mi | ★★★★★ | 0 | 0 |
| Ansley Cove Healthcare And Rehabilitation | 3.5 mi | ★★★★★ | 16 | 3 |
| Aviata At Rosewood | 3.6 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Altamonte Springs | 4.1 mi | ★★★★★ | 4 | 0 |
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