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 Island Lake Center during CMS and state inspections, most recent first.
The facility failed to ensure its QAA/QAPI committee carried out performance improvement activities to sustain prior improvement measures. The same issues cited on the prior survey reappeared, including medications left at bedside and infection control concerns involving PPE use for a resident on standard precautions. The Administrator stated monthly QAPI meetings were held, but she had only been at the facility for about 3 weeks and had not yet reviewed the prior survey results, plan of correction, or related audits.
A resident with dementia, cognitive impairment, and hospice services had DNR and advance directive documentation in the EMR, and the daughter stated she had told staff the resident did not want to be hospitalized. Despite physician documentation that the POA consented to DNR/DNI, comfort care, and do not hospitalize orders, the resident was transferred to the hospital after coffee-ground emesis, and the SSD and DON could not explain why a DNH order was not obtained or why the EMR was not updated to reflect the resident’s wishes.
A resident admitted with major depressive disorder later had ongoing depression symptoms, poor appetite, and sleep difficulty, and was prescribed Mirtazapine for depression-related poor appetite. Although the initial PASARR Level I was negative, the MDS Director and SSD confirmed a new PASARR Level I was not requested after the resident’s diagnosis changed.
Failure to Complete Required PASARR Level II Evaluation: A resident admitted with bipolar disorder, GAD, MDD, and adjustment disorder had a Level I PASARR that identified serious mental illness and indicated a Level II eval was required before admission. The record contained no Level II PASARR determination, and the SSD confirmed the required screening had not been completed.
Failure to provide an individualized activity program: A resident with blindness, moderate cognitive impairment, and full-assist needs had documented preferences for sports, music, audible books, bingo, and dining room participation, but had no active activity care plan. He was repeatedly observed in bed with no audible TV, reported he was not offered meals in the dining room or activities, and said staff did not read the menu to him. The Activity Director acknowledged the preferences form was not entered into the record until later and that no activity care plan existed; the DON stated the facility had no activity policy.
A resident with dementia and atopic dermatitis was repeatedly observed scratching dry, reddened, cracked skin, but the facility did not document or carry out the dermatologist’s recommendation for Permethrin cream. The MAR/TAR had no order or refusal record, and there was no documentation that the PCP or family was contacted for approval or that the resident or representative refused the treatment.
A resident with dementia, Parkinson's disease, and diabetes had shortness of breath and low O2 saturation, leading to orders for continuous O2 at 2 LPM, a portable tank, twice-daily pulse oximetry, and a pulmonology consult. Staff did not document the actual O2 saturation values, did not document refusals to wear oxygen, and could not provide consult documentation. The resident was observed without the nasal cannula in place, and an RN was unaware of the continuous oxygen order and said she would change it to PRN.
Medication administration errors occurred with three residents. One confused resident with dementia and dysphagia had medications left at the bedside and signed as given even though the resident had no order or assessment for self-administration. Another resident received only one acetaminophen tablet instead of the ordered two-tablet dose, and a third resident received an inhaler without mouth rinsing afterward and was also given the wrong cranberry dose from house stock.
Failure to Follow Contact Precautions for a Resident with Possible Scabies: A nurse entered a room with a Contact Precaution sign posted and administered meds to a resident without gown or gloves, then later used PPE after stating she believed the roommate had scabies and was on contact precautions. The resident on precautions had a physician order for contact precautions for possible scabies, and the IPN confirmed the nurse had mistaken which roommate required PPE.
The facility did not provide a homelike dining environment for residents in the Vista View unit dayroom. Residents were observed dining without tablecloths or centerpieces, and meal trays were not properly set on tables. The Director of Nursing acknowledged the importance of a social dining experience, but residents often ate in their rooms due to activities in the dayroom. The facility's policy emphasized a dignified dining experience, which was not met in this instance.
A facility failed to evaluate a resident for safe self-administration of medication and did not obtain a physician order for it. The resident, with mild neurocognitive disorder and other conditions, was found with Vicks VapoRub in her room, which she applied nightly without a physician's order or documented assessment. The LPN and UM were unaware of the resident's use of the medication until it was discovered during a survey.
A resident with multiple health issues was not involved in her care plan development, as the facility failed to invite her or document her participation in care plan meetings. Despite protocols to notify residents and families, there was no evidence of the resident's involvement, which was acknowledged by facility staff.
A facility failed to maintain a sanitary environment by not ensuring reusable oxygen humidifier bottles were cleaned per manufacturer's guidelines for a resident with chronic conditions. The LPN responsible for cleaning admitted to not following the disinfection step and failed to document the process. The DON confirmed the oversight, and the Facility Management Director preferred replacing bottles instead of disinfecting them.
QAPI Committee Failed to Sustain Prior Improvement Measures
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee conducted performance improvement activities to verify that prior improvement measures were sustained. The facility's undated QAPI Program stated that the process was intended to track and measure performance, identify and prioritize quality deficiencies, develop and implement corrective action or performance improvement activities, and monitor or evaluate the effectiveness of those activities and revise them as needed. During the previous recertification survey conducted 1/27/25 through 1/30/25, the facility was cited for medications left at bedside and infection control issues. During the current survey, the same types of noncompliance were again identified, including medications observed at bedside and infection control concerns related to PPE use for a resident on standard precautions. The Administrator stated the facility held monthly QAPI meetings and reviewed areas including infection control and prior survey results, but she had only been at the facility for about 3 weeks, the monthly QAPI meeting was scheduled for the following week, and she had not yet reviewed the previous survey results, the prior plan of correction, or related audits.
Advance Directive Wishes Not Reflected or Honored
Penalty
Summary
The facility failed to honor a resident’s advance directive wishes and failed to ensure the medical record accurately reflected do not hospitalize preferences for one resident reviewed. The resident was admitted with diagnoses including senile degeneration of brain, depression, age-related physical debility, cognitive communication deficit, and vascular dementia, and a significant change MDS showed moderate cognitive impairment and hospice services. The EMR contained a DNR physician order, an advance directive care plan indicating DNR status, and an advance directive discussion document stating the resident wished CPR to be withheld. The resident’s daughter stated she had told staff her mother did not want to be hospitalized, but the resident was sent to the hospital anyway and later returned before treatment was provided. A physician progress note documented discussion of advance directives and stated the POA did not want heroic life-prolonging measures, including no tube feeds, no hemodialysis, no mechanical life support, and that the HCP/POA consented to DNR/DNI, palliative care, comfort care measures, and do not hospitalize orders. Despite this, the record showed the resident vomited coffee-ground emesis, the physician ordered transfer to the hospital for further evaluation, and the transfer occurred. The SSD and DON both stated they were aware of the resident’s no-hospitalization wishes but could not explain why no do not hospitalize order was obtained or why the advance directives were not updated in the EMR.
Failure to Obtain New PASARR Screening After Change in Mental Health Diagnosis
Penalty
Summary
The facility failed to request a new Preadmission Screening and Resident Review (PASARR) Level I screening for a resident who later had a new mental illness diagnosis. The resident was admitted from an acute care hospital with a diagnosis of major depressive disorder, and her Quarterly MDS showed a BIMS score of 15 out of 15, indicating she was cognitively intact. Her initial PASARR Level I screening completed on 9/23/25 was negative for mental illness or intellectual disability. Record review showed the resident was prescribed Mirtazapine on 3/04/26 for poor appetite related to depression. On 3/23/26, she was observed in her room sitting in her wheelchair with her lunch tray in front of her but had not eaten; she stated she was not feeling hungry, did not feel like eating, was having trouble adjusting to living in the facility, and missed being at home. Psychology progress notes showed she had reported feeling depressed, having difficulty sleeping, and poor appetite, with a treatment plan to monitor mood or behavior changes and continue antidepressants. The Director of MDS and the Social Service Director stated they reviewed PASARRs on admission and during clinical meetings, and both confirmed the resident had not been screened for a new PASARR Level I despite the change in diagnosis.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with identified mental illness for a Level II PASARR evaluation and determination before admission. Resident #106 was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, major depressive disorder, and adjustment disorder. The admission MDS dated 1/13/26 showed a BIMS score of 11/15, indicating moderate cognitive impairment, and documented active diagnoses of anxiety disorder and bipolar disorder, along with antipsychotic, antianxiety, and antidepressant medications. Review of the electronic medical record showed a Level I PASARR screening form dated 1/06/26 that identified bipolar disorder and depressive disorder and indicated the resident met criteria for a serious mental illness requiring a Level II evaluation prior to admission. The record did not contain a Level II PASARR Evaluation and Determination form. The Social Services Director stated PASARR screenings for new admissions were reviewed in daily clinical meetings, that Level II screenings were submitted if indicated, and after reviewing the form for resident #106, verified that a Level II screening was required but had not been completed.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized ongoing activity program designed to meet the interests and support the physical, mental, and psychosocial well-being of one resident reviewed for activities. The resident was admitted with arthritis of the hip, type 2 diabetes, total retinal detachment of the right eye, and blindness in the left eye. The MDS assessment showed a BIMS score of 10/15, indicating moderately impacted cognitive impairment, and documented that the resident required full assistance with meals, toileting, hygiene, and transfers. The resident’s stated preferences included television movies, sports, classic rock and country music, audible books, sports, bingo, and activities both inside and outside the room. Review of the record showed no active activity care plan. During multiple observations, the resident was repeatedly found lying in bed with no audible television, and he stated he had to wait for help with breakfast because he was blind, was never sure what time of day it was, and gauged time by meals. He reported he could not see the television remote, liked to listen to sports, was not aware of the dining room or resident activities, and said no one had offered to let him eat in the dining room, attend activities, or bring activities to him. He also stated no one asked if he wanted to sit in a chair except when PT came right before dinner. The resident’s brother stated he was always in bed and was not aware of him participating in any facility activities, and the Activity Director acknowledged the admission lifestyle and activity preferences evaluation had been completed on paper but not scanned into the record until later and that there was no activity care plan. The DON stated the facility had no activity policy.
Failure to Follow Dermatology Treatment Recommendation
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when it did not acknowledge and follow a consultant dermatologist’s recommendations for a resident with vascular dementia and atopic dermatitis. The resident had severe cognitive impairment, was dependent for toileting, personal hygiene, dressing, and mobility, and was observed repeatedly scratching her wrists, hands, abdomen, and thighs during the survey. Her skin was described as dry, cracked, reddened, and scratched, and she reported that her hands itched. A dermatology consult documented dry patches, dark spots, rough bumps on the resident’s extremities, and dermatitis of the chest, back, and abdomen with persistent itching. The dermatologist recommended Permethrin 5% cream be applied overnight and washed off in the morning, with a repeat treatment in seven days. However, the resident’s current physician orders contained no order for Permethrin, and the March 2026 MAR and TAR contained no record of the treatment or any refusal. The record also lacked documentation that the primary physician or the resident’s representative was contacted for approval of the dermatologist’s recommendation, and there was no progress note showing that the family refused the treatment or that staff attempted to apply it and the resident refused. During the survey, staff were initially unaware of the resident’s skin problem, and when the unit manager and LPN later reviewed the chart, they confirmed there was no corresponding order in the EMR. The DON acknowledged that a progress note should have been present if the son refused the treatment, but the medical record contained no such documentation.
Failure to Follow Oxygen Orders and Document Respiratory Monitoring
Penalty
Summary
The facility failed to follow physician orders for a resident with Parkinson's disease, Alzheimer's disease, type 2 diabetes mellitus, and dementia who had a change in condition with shortness of breath and an oxygen saturation of 88%. After that assessment, the physician ordered continuous oxygen at 2 LPM via nasal cannula, a portable oxygen tank for 2 LPM nasal cannula, oxygen saturation monitoring twice daily, and a pulmonology consult. The resident's care plan identified risk for altered respiratory status and included oxygen administration and oxygen saturation monitoring, but the most recent revision did not address non-compliance with oxygen therapy and had no related interventions. The medical record did not show the actual oxygen saturation values for the ordered monitoring, and the nurses' progress notes did not document the resident's refusal to wear oxygen or any pulmonary consultation documentation. The MAR showed check marks for oxygen saturation monitoring, but the actual percentages were not recorded. During observation, the resident was seen sitting in the common area and later again without the nasal cannula in place as ordered. Staff confirmed there was no oxygen concentrator or portable oxygen tank at the bedside, and one RN stated she was not aware the resident was supposed to be on continuous oxygen and said she would call the doctor to change the order to as needed. The DON stated the oxygen saturation checks should include the actual numbers, but could not explain how the physician would know the resident's oxygen level without that documentation. The attending physician and APRN both stated they expected the actual oxygen saturation measurements to be recorded and said staff had reported the resident was fine even when their own checks showed low oxygen saturation. The APRN also stated staff told her the resident would not be compliant with wearing oxygen, but the resident understood the need for it and agreed to wear it. The facility could not provide documentation of the pulmonology consult, and its policy required physician orders to be followed as prescribed and, if not followed, recorded in the resident's medical record during that shift.
Medication Administration Errors Involving Bedside Medications, Incorrect Dosing, and Inhaler Technique
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for three residents. The report identified errors involving leaving medications at the bedside for a resident who was confused and had no order or assessment for self-administration, giving an incorrect dose of acetaminophen to a resident with osteoarthritis, prostate cancer, muscle weakness, and chronic pain, and administering an inhaler and oral tablets incorrectly to a resident with systemic lupus erythematous, immunodeficiency, chronic kidney disease stage 3, cognitive communication deficit, and colostomy status. For the first resident, the physician ordered Sucralfate 1 gram dissolved in water before meals and at bedtime and Pantoprazole 40 mg twice daily, with instructions not to crush, chew, or split the pantoprazole. The resident had diagnoses including Alzheimer’s disease, dementia with psychotic disturbance, GERD, and dysphagia. During observation, two tablets were found in a cup on the resident’s nightstand, and the assigned LPN confirmed the resident was confused and not able to self-administer medications. The LPN stated the medications had likely been left by the night shift nurse and acknowledged the MAR had been signed as administered even though the medications were still at the bedside. For the second resident, an RN observed medication administration and gave only one 500 mg acetaminophen tablet instead of the ordered two tablets for a total dose of 1000 mg. The nurse had pulled one tablet from each of two peel packs and one tablet from a bottle, then administered the medications. She later acknowledged she had seen only the 500 mg strength and did not realize the order required two tablets. For the third resident, an LPN administered a metered dose inhaler and then oral medications, but did not have the resident rinse the mouth afterward. The LPN also gave the wrong cranberry dose by using house stock without verifying it matched the ordered 300 mg tablet. The DON acknowledged both medication errors and stated nurses were expected to verify resident orders before administering medications.
Failure to Follow Contact Precautions for Resident with Possible Scabies
Penalty
Summary
The facility failed to ensure staff followed transmission-based precautions for a resident on contact precautions for possible scabies. On 3/22/26 at 10:15 AM, room [ROOM NUMBER]'s door was open with a Contact Precaution sign posted, but the sign did not identify which bed was on precautions. A nursing student performed hand hygiene, donned gloves, and entered the room to see resident #56 in the B bed. RN H then completed hand hygiene and entered the room to administer oral medications to resident #56 without donning gloves or a gown. A few minutes later, RN H stated that resident #9 had scabies and was on contact precautions. At 10:30 AM, RN H completed hand hygiene, donned a gown and gloves, and re-entered the room to administer inhaled medications to resident #56, explaining she wore PPE this time because resident #9 used the same bathroom and was on contact precautions for scabies. Later that morning, resident #9 stated that resident #56, her roommate, had scabies, not her. The medical record for resident #56 showed a physician order for contact precautions for possible scabies for 14 days beginning 3/19/26, and the Infection Preventionist Nurse confirmed that resident #56 had the contact precaution order and that RN H had mistaken resident #9 for the resident on precautions.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents in the Vista View unit dayroom. Observations revealed that residents were seated around tables without tablecloths or centerpieces, and staticky music played in the background. Meal trays were delivered with dishes and utensils left on the trays, rather than being set on the tables, which did not promote a homelike dining experience. The Social Services Assistant attempted to find appropriate dining music but was unsuccessful due to persistent static. The Activities Director and Vista View Unit Manager acknowledged that the dining setup was not homelike and explained that residents often ate in their rooms due to ongoing activities in the dayroom. The Director of Nursing confirmed that leaving dishes on trays during meals in the dining room was not appropriate and emphasized the importance of a social dining experience. The facility's policy on dining services indicated that a pleasurable dining experience should be provided in a courteous and dignified manner, with adequate nursing personnel to assist with eating. However, the practice of having residents eat in their rooms or without proper dining setup in the dayroom was acknowledged as not aligning with these standards. The Vista View Unit Manager noted that the main dining room downstairs was larger and catered to residents with better cognition, which contributed to the differences in dining experiences between the units.
Failure to Evaluate and Obtain Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a resident was evaluated for safe self-administration of medication and did not obtain a physician order for self-administration of medication. Resident #65, who was admitted with mild neurocognitive disorder, chronic kidney disease, and lack of coordination, was observed with a bottle of Vicks VapoRub in her room, which she applied under her nose nightly. There was no physician's order for the Vicks VapoRub or documentation of a self-administration of medication assessment in the resident's medical record. The Licensed Practical Nurse (LPN) and the Unit Manager (UM) were unaware of the resident's possession and use of the medication until it was discovered during the survey. The UM confirmed the absence of a physician's order and the required interdisciplinary team assessment for safe self-administration of medication.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to ensure a resident was involved in developing and making decisions regarding her care plan. The resident, a female with multiple diagnoses including muscle wasting, traumatic subdural hemorrhage, diabetes, repeated falls, dementia, and major depressive disorder, was not invited to her care plan meetings. Despite the facility's protocol that residents should be informed and invited to participate in their care plan meetings, there was no documentation indicating that the resident was invited, attended, or declined participation in her care plan meetings on several occasions. Interviews with facility staff, including the Unit Manager and MDS Coordinator, revealed that the facility's process involved notifying residents and their families about care plan meetings. However, the documentation reviewed did not reflect that the resident or her representative was informed or involved in the care planning process. The MDS Coordinator acknowledged the lack of documentation and stated that the facility did not have a specific policy regarding resident participation in care plan meetings, although they followed the MDS 3.0 Resident Assessment Instrument Manual. The Director of Nursing also confirmed the absence of documentation indicating the resident's involvement in her care plan meetings.
Failure to Properly Clean and Disinfect Oxygen Humidifier Bottles
Penalty
Summary
The facility failed to maintain a sanitary environment by not ensuring reusable oxygen humidifier bottles were cleaned according to the manufacturer's guidelines for a resident using humidified oxygen. The resident, who had chronic obstructive pulmonary disease, heart failure, sick sinus syndrome, and a recent COVID-19 diagnosis, was observed with a nasal cannula connected to an oxygen concentrator with a reusable humidifier bottle. The bottle was dated from several months prior, indicating it had not been replaced or properly maintained. The Director of Nursing (DON) confirmed the bottle's date and the lack of disinfection as per the manufacturer's instructions. The Licensed Practical Nurse (LPN) responsible for cleaning the humidifier bottle admitted to only washing it with soap and water, without following the disinfection step outlined in the user's manual. The LPN also failed to document the cleaning process in the resident's medical record. The Assistant Director of Nursing (ADON) reviewed past in-service education on infection control but could not confirm if the manufacturer's guidelines were adequately covered. The Facility Management Director and his staff were not performing the disinfection process, opting instead to replace the bottles, which was not documented. The DON acknowledged the oversight in documentation and adherence to the cleaning protocol.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longwood Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Altamonte Springs | 2.4 mi | ★★★★★ | 4 | 0 |
| Village On The Green | 2.6 mi | ★★★★★ | 0 | 0 |
| Aviata At Lake Mary | 4.3 mi | ★★★★★ | 0 | 0 |
| Harborview Health Center West Altamonte | 4.5 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.