Above 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 Hunters Creek Nursing And Rehab Center during CMS and state inspections, most recent first.
Inaccurate fluid intake documentation for a resident on a fluid restriction. The resident had DM2, COPD, CKD stage 4, and HF, and the care plan and MD order required a 1900 ml fluid restriction with nursing documenting the amount provided each shift. Instead, the MAR contained entries such as "n" and "yes" rather than actual ml amounts on multiple day shifts. An LPN could not explain the inaccurate charting, and the UM and administrator’s representative confirmed the documentation was not accurate.
The facility failed to properly store and label food items in the walk-in cooler, with several perishable items found beyond their discard dates. Additionally, hot foods were not held at the correct temperatures before service, with chicken noodle soup and cream of chicken soup not reheated to the required temperature. The facility's policy lacked guidance on the storage life of cheese, leading to uncertainty among staff.
The facility failed to treat residents with dignity during meal assistance. A resident with dementia and other conditions was left unattended with a meal tray, and staff referred to her as a 'feeder.' Another resident was also referred to as a 'feeder,' and an RN fed her while standing, against facility policy. The term 'feeder' was commonly used, which the Administrator recognized as a dignity issue.
A resident with intact cognition and multiple diagnoses was not managed according to pharmacy recommendations for Lidocaine patch use. The patch was left on for more than 12 hours, contrary to instructions, and the facility failed to act on the pharmacist's advice. The DON had signed the recommendation, but it was not implemented, leading to a deficiency in medication management.
A resident with diabetes in an LTC facility preferred a sandwich as a nighttime snack for blood sugar control. However, the sandwich was often left unrefrigerated for several hours, posing a risk of foodborne illness. The facility's dietary and nursing staff failed to coordinate effectively to ensure the sandwich was stored safely until the resident was ready to eat it. The facility's Administrator acknowledged the responsibility to provide food safely, regardless of resident requests.
A resident developed a stage 4 pressure ulcer within 12 days of admission due to the facility's failure to identify early skin breakdown and initiate timely wound care. Despite being assessed as having a mild risk for pressure ulcers, the facility did not conduct thorough skin evaluations or follow up on concerns raised by the resident's daughter. The resident's condition worsened, leading to hospitalization and significant physical and psychosocial harm.
A facility failed to ensure an accurate MDS assessment for a resident, incorrectly documenting two unstageable pressure injuries. The resident was admitted for short-term rehabilitation with no pressure injuries noted upon hospital discharge. Despite facility assessments showing intact skin, the Lead MDS Coordinator assumed the presence of pressure injuries based on small white areas on the skin, leading to inaccurate MDS documentation. The DON confirmed the interdisciplinary team found no evidence of pressure injuries at admission, highlighting a failure in the assessment process.
A resident admitted for short-term rehabilitation developed a stage 4 pressure injury due to the facility's failure to update the baseline care plan with appropriate interventions. Initially, the resident's skin was noted to be intact, but a new wound was discovered, and the care plan was not revised to address the risk factors and promote healing. The facility's staff acknowledged the care plan was incomplete and not updated in a timely manner, and the resident's family was not informed of the wound's severity.
A resident with severe cognitive impairment and multiple medical conditions eloped from a facility due to inadequate supervision and failure to implement preventive measures. Despite being assessed as an elopement risk, the resident was able to exit through an unlocked door, leading to Immediate Jeopardy. Staff were aware of the resident's wandering behaviors but did not document or implement additional supervision.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after a receptionist unlocked the door without verifying his identity. The resident, who had removed his alerting bracelet, was found by law enforcement with minor injuries over an hour later. The facility failed to ensure proper supervision and secure environment, contributing to the incident.
Inaccurate Fluid Intake Documentation for Resident on Fluid Restriction
Penalty
Summary
The facility failed to accurately obtain and document fluid intake for a resident on a fluid restriction. The resident had diagnoses including type 2 diabetes, COPD, CKD stage 4, and heart failure, and the care plan identified the resident as at risk for decreased nutritional status and dehydration related to diabetes, CKD, edema, hyponatremia, and hypoosmolality. The care plan and physician orders required a 1900 ml fluid restriction, with nursing responsible for documenting the amount of fluid provided each shift. Review of the resident’s MAR showed that nursing staff documented "n" on multiple day shifts in April and May and "yes" on one day shift entry, rather than documenting the actual milliliters of fluid provided as ordered. During interview, an LPN stated the resident was on a fluid restriction due to low sodium and initially said he communicated with the CNA to obtain and document fluid intake, but then stated he did not coordinate with CNAs regarding the resident’s fluid intake or restrictions and could not explain the inaccurate entries. The UM and the Administrator’s representative reviewed the MAR and confirmed the fluid intake documentation was inaccurate. The facility policy required nursing personnel to keep an accurate record of fluid balance and to document the total intake at the end of each shift.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items in the walk-in cooler, as observed during a survey. Several perishable food items, including turkey slices, ham, mozzarella cheese, goat cheese, and Italian bread, were found to be stored beyond their recommended discard dates according to the facility's policy. Additionally, opened containers of mayonnaise, Italian salad dressing, and sour cream were not labeled with the date they were opened, which is a requirement of the facility's food storage and labeling policy. The Certified Dietary Manager (CDM) was unable to provide specific guidance on the shelf life of certain items, such as cheese, and was not aware of the exact policies regarding the storage duration of unopened turkey slices and raw ground beef. The facility also failed to ensure that hot foods were held at the correct temperatures before service. During the survey, individually portioned bowls of chicken noodle soup were observed to be held without a heat source and were not reheated to the required temperature of 165 degrees Fahrenheit before being served. The CDM and dietary staff were aware of the requirement to reheat food to the correct temperature but failed to do so in this instance. Additionally, cream of chicken soup was found to be sitting on the counter without a heat source and required reheating to reach the appropriate temperature. The facility's food storage and labeling/dating policy, provided by the Regional Healthcare Manager, indicated that all food items should be labeled with the date of receipt, opening, and storage after preparation. The policy also specified discard timelines for various food items, such as raw ground beef, unsliced ham, and vacuum-packed deli meats. However, the policy did not include guidance for the storage life of cheese, leading to uncertainty among staff about how long cheese could be kept after opening.
Failure to Ensure Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as observed in the cases of two residents who required assistance with meals. Resident #11, who had a history of dementia, hemiplegia, hemiparesis, dysphagia, and aphasia, was found lying in bed with her lunch tray on the bedside table, unattended. A CNA referred to her as a 'feeder' and admitted to not having received training on assisting residents with meals. The facility's policy emphasized treating residents with dignity and using their preferred names, but this was not adhered to in the case of Resident #11. Similarly, another incident involved Resident #48, where a CNA referred to the resident as a 'feeder' in the presence of an RN. The RN left the meal tray uncovered in front of the resident and later fed her while standing over her, contrary to the facility's policy, which required staff to sit next to residents while assisting them with meals. The term 'feeder' was also found on the master roster, indicating its common use in the facility, which the Administrator acknowledged as a dignity issue.
Failure to Address Pharmacy Recommendation for Lidocaine Patch
Penalty
Summary
The facility failed to address a pharmacy recommendation for a resident who was receiving a Lidocaine patch for pain management. The resident, who had intact cognition, was readmitted with multiple diagnoses including Parkinson's Disease and congestive heart failure. The pharmacy recommendation, issued in October, advised that the Lidocaine patch should be removed after 12 hours and not exceed three patches within a 24-hour period. However, the resident reported that the patch was not removed at night, and the LPN confirmed that the patch was often left on for more than 12 hours, contrary to the instructions. The Director of Nursing had signed the pharmacy recommendation, but it was not implemented, and the Regional Nurse Consultant could not explain why the recommendation was not addressed. The Consultant Pharmacist stated that his role included reviewing previous recommendations to ensure completion and that using the Lidocaine patch longer than recommended could lead to over-absorption. The facility's policy on Medication Regimen Review emphasized the importance of acting upon pharmacy recommendations, but in this case, the recommendation was not followed, leading to a deficiency in medication management for the resident.
Inadequate Food Safety Practices for Diabetic Resident
Penalty
Summary
The facility failed to ensure that staff had the appropriate competencies and skills to carry out the functions of the food and nutrition service, which led to a potential risk of foodborne illness for a resident with diabetes. The resident preferred a sandwich as a nighttime snack for blood sugar control but often received it on her dinner tray, which she did not consume until several hours later. This practice resulted in the sandwich being left unrefrigerated for an extended period, posing a safety risk. The resident's dinner meal typically arrived before 6:00 PM, and she would eat the sandwich between 10:30 PM and 12:30 AM, well beyond the safe time for perishable food to remain unrefrigerated. The Registered Dietitian and Certified Dietary Manager were aware of the resident's preference for a sandwich as a nighttime snack. However, they did not ensure that the sandwich was stored safely until the resident was ready to consume it. The facility's Administrator acknowledged the responsibility to provide food safely, regardless of resident requests. The Certified Nursing Assistants confirmed the resident's routine of eating the sandwich late at night but were not aware of the exact time. The deficiency highlights a lack of communication and coordination among dietary and nursing staff to ensure food safety for the resident.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the development and worsening of a pressure injury for a resident. Upon admission, the resident's skin was intact, but within 12 days, she developed a stage 4 pressure injury. The facility did not identify early signs of skin breakdown or promptly initiate wound care and treatment. The resident's daughter reported a skin issue to the staff, but there was no documented follow-up or intervention until the wound had significantly worsened. The resident was admitted with no pressure injuries and was assessed as having a mild risk for pressure ulcer development. Despite this, the facility's staff did not conduct thorough and timely skin evaluations. A request for a skin evaluation by the resident's daughter was not acted upon promptly, and the resident's condition deteriorated. The wound nurse eventually identified a stage 4 pressure injury, but by then, the wound had already progressed significantly, requiring surgical intervention and hospitalization. The facility's care plan for the resident did not include adequate interventions to prevent skin impairment, and the staff failed to communicate effectively about the resident's condition. The resident's daughter was not informed of the severity of the wound until it required hospital transfer. The lack of timely and appropriate interventions led to the resident suffering physical and psychosocial harm, including a decline in mobility and depression.
Inaccurate MDS Assessment of Pressure Injuries
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, which inaccurately reflected the presence of pressure injuries. The resident, a female admitted for short-term rehabilitation, was initially assessed with no pressure injuries upon discharge from the hospital. However, the MDS Admission assessment incorrectly documented two unstageable pressure injuries, despite the absence of such findings in the medical record and assessments conducted by the facility's staff. The Lead MDS Coordinator, responsible for completing the MDS assessment, relied on various sources of information, including staff interviews and medical records. Despite the documentation indicating intact skin with no open areas, the coordinator assumed the presence of pressure injuries based on the description of small white areas on the resident's skin. This assumption led to the inaccurate documentation of pressure injuries in the MDS assessment, which was not supported by the facility's own skin assessments and lack of physician orders for wound care. The Director of Nursing (DON) confirmed that the interdisciplinary team, including the Lead MDS Coordinator, reviewed the resident's chart and found no evidence of pressure injuries at the time of admission. The DON acknowledged that the Lead MDS Coordinator should have sought clarification to ensure the accuracy of the MDS assessment. The facility's policy emphasized the importance of accurate MDS assessments, which are foundational for developing appropriate care plans, but this process was not followed correctly in this instance.
Failure to Update Baseline Care Plan for Pressure Injury
Penalty
Summary
The facility failed to develop, implement, and update an appropriate baseline care plan for a resident, leading to a deficiency in managing the risk factors for skin impairment. Upon admission, the resident was noted to have clear skin integrity with no conditions present, but a small, white intact area was observed on her sacrum and left buttock. Despite this, the baseline care plan only included an intervention to turn and reposition the resident, which was not updated when a new wound was discovered. The resident's condition worsened when a stage 4 pressure injury was identified on her sacrum, yet the care plan was not updated to include necessary interventions to prevent further deterioration and promote healing. The facility's staff, including the Lead MDS Coordinator, acknowledged that the baseline care plan was incomplete and not updated in a timely manner. The resident's daughter was not informed of the severity of the wound or any noncompliance issues, and there was no documentation of the resident refusing care. The Director of Nursing confirmed that the baseline care plans did not reflect the facility's expected processes. The facility's policy required the development of a baseline care plan to include necessary instructions for effective, person-centered care, but this was not adhered to, resulting in inadequate care for the resident's pressure injury.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect by not implementing measures to prevent elopement. The resident, a male with severe cognitive impairment and multiple medical conditions, was admitted from a hospital where he was determined to be at risk of harm and falls without 24-hour supervision. Despite being assessed as an elopement risk, the facility did not provide adequate supervision, allowing the resident to exit the building unsupervised. On the day of the incident, the resident was able to leave the facility through an unlocked lobby door, which was opened by a receptionist who mistook him for a visitor. The resident, who was wearing an alerting bracelet, was not stopped or questioned, and he managed to walk across a high-traffic road to a nearby apartment complex. The facility was unaware of his absence until a CNA noticed he was missing. The resident was later found by police with minor injuries, highlighting the facility's failure to implement preventive interventions to mitigate the risk of elopement. Interviews with staff revealed that the resident had been exhibiting wandering and exit-seeking behaviors, which were known to the staff. However, no additional supervision or interventions were documented or implemented to address these behaviors. The facility's lack of action and failure to ensure a secure environment placed the resident at risk, resulting in Immediate Jeopardy.
Removal Plan
- The receptionist on duty was suspended.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held.
- An audit was conducted to ensure all current residents were present, alerting bracelets and physician's orders were in place, and elopement risk evaluations were validated.
- Door system alarm checks for proper functioning were completed.
- The Nursing Home Administrator educated the receptionist who was on duty.
- Audits were conducted to ensure BIMS, evaluations, care plans, leave of absence and alerting bracelet orders were correct and present for all new admissions.
- Elopement book audits were conducted to ensure accuracy.
- A total of nine staff assigned receptionist duties were re-educated by the Business Office Manager regarding the front door process and received competency checks.
- A majority of staff were re-educated regarding Abuse, Neglect, and Exploitation that included at-risk resident elopement risk identification and implementation of preventive measures, protection of residents from harm, identification of resident neglect, signs and symptoms of elopement risk including wandering, and expectations for a missing alerting bracelet.
- An Ad Hoc QAPI meeting was conducted to ensure all interventions were in place and root cause analysis was completed.
- Ongoing audits were continued for new admissions to ensure accuracy of the BIMS, Leave of Absence, bracelets, alerting batch orders, and care plans.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident, who was identified as being at high risk for elopement. The resident, who had severe cognitive impairment and a history of wandering, was able to exit the facility unsupervised when a receptionist unlocked the front door without verifying his identity. The resident was later found by law enforcement in a nearby apartment complex parking lot with minor injuries, more than an hour after he left the facility. The resident had been admitted to the facility with multiple medical conditions, including dementia, and was assessed as being at risk for elopement. Despite this, the facility failed to ensure that the alerting bracelet, which was supposed to prevent such incidents, was functioning properly. The resident was able to remove the bracelet using a butter knife, which prevented the exit alarm from sounding when he left the building. Staff members, including the receptionist, did not follow established procedures to verify the identity of individuals exiting the facility, contributing to the resident's unsupervised departure. Interviews with staff revealed that the resident had been exhibiting exit-seeking behavior and was anxious about leaving the facility. Despite these signs, the facility did not take adequate measures to prevent the elopement. The receptionist, who was not aware of the elopement risk binder, mistakenly believed the resident was a visitor and allowed him to exit without following the sign-out process. This oversight, combined with the resident's ability to remove the alerting bracelet, led to the resident's elopement and placed him at risk of serious harm.
Removal Plan
- The receptionist on duty was suspended.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held.
- An audit was conducted to ensure all current residents were present, alerting bracelets and physician's orders were in place, and elopement risk evaluations were validated.
- Majority of staff were re-educated regarding at-risk resident elopement risk identification and implementation of preventive measures, identification of exit-seeking residents and process to minimize risk, protection of residents from harm, signs and symptoms of elopement risk including wandering, expectations for a missing alerting bracelet, sign in/out process, and elopement books.
- The NHA educated the Receptionist who was on duty.
- Door system alarm checks for proper functioning were completed.
- Audits were conducted to ensure BIMS, evaluations, care plans, and Leave of Absence and alerting bracelet orders were correct and present for all new admissions.
- Elopement book audits were conducted to ensure accuracy.
- A total of nine staff assigned receptionist duties were re-educated by the Business Office Manager regarding the front door process and received competency checks.
- The front door process, Receptionist Competency for Visitors and Vendors was laminated and placed at the front reception desk.
- An Ad Hoc meeting was conducted to ensure all interventions were in place and a root cause analysis was completed.
- Ongoing audits were to be continued for new admissions to ensure accuracy of the BIMS, Leave of Absence, bracelets, alerting batch orders, and care plans.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 9 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Kissimmee Nursing & Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Aviata At Kissimmee Gardens | 3.2 mi | ★★★★★ | 6 | 0 |
| Terrace Of Kissimmee, The | 3.6 mi | ★★★★★ | 2 | 0 |
| Rehabilitation Center Of Orlando | 4.4 mi | ★★★★★ | 3 | 0 |
| Kissimmee Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 0 | 0 |
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