Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Bennet Center For Rehabilitation & Healing during CMS and state inspections, most recent first.
Staff failed to ensure dishes were washed at the required temperature, as the dish machine operated below the manufacturer's specified 120°F. Dishes processed at the lower temperature were not removed or rewashed, and were subsequently mixed with other clean dishes and used for meal service, contrary to professional standards.
Nursing staff administered Metoprolol to a resident with hypertension on multiple occasions despite physician-ordered parameters to hold the medication for low systolic blood pressure. Several nurses confirmed the medication was given in error, and there was no documentation explaining the deviation from the order. The DON verified that staff are expected to follow physician orders and that the facility's policy requires vital signs to be checked prior to administration when indicated.
A resident with multiple medical conditions, including a history of stroke and diabetes, exhibited blood-tinged urine and had a physician's order for urinalysis and urine culture. The order was not carried out, and the failure was not communicated to the provider or documented appropriately. Over several days, the resident's condition worsened, culminating in septic shock and emergency hospitalization. The facility did not recognize or investigate the missing test until the family inquired, and did not report the incident as possible neglect until prompted by surveyors.
A resident with multiple medical conditions developed septic shock after nursing staff failed to collect a urine specimen for a physician-ordered urinalysis and culture, did not notify the provider of the missed test, and marked the order as completed in the MAR. The lack of follow-up and communication resulted in the resident's UTI going undiagnosed and untreated, ultimately requiring emergency hospitalization and intensive care.
A resident with cognitive impairment and a recent UTI requiring an indwelling urinary catheter did not have this device addressed in their Comprehensive Care Plan, despite assessment triggers and ongoing antibiotic treatment. The omission was confirmed as an oversight by the MDS Coordinator.
Failure to Wash Dishes at Required Temperature in Dish Machine
Penalty
Summary
The facility failed to ensure that dishes were washed at the appropriate temperature according to the dish machine's data plate and manufacturer's instructions. During a kitchen observation, a dietary aide was seen placing dishes into the dish machine, and another staff member removed items from the machine and placed them with other eating items. The temperature dial on the dish machine registered at 110°F, which was below the required 120°F as indicated on the machine's data plate. The Certified Dietary Manager (CDM) confirmed the low temperature and stated that the machine should wash at 120°F or higher. Despite this, the CDM did not instruct staff to remove or rewash the dishes that had already been processed at the incorrect temperature. Later, dietary staff were observed preparing meal trays using dishes that had been washed at the insufficient temperature, and these dishes were mixed with other clean dishes. The CDM was unaware that the improperly washed dishes had not been pulled from service and had been mixed in with other clean items. The deficiency was identified through observation, interview, and record review, and it was confirmed that the dish machine was not operating in accordance with professional standards and the manufacturer's instructions, as required by the Food and Drug Administration Food Code.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to administer blood pressure medication according to physician-ordered parameters for one resident with a diagnosis of hypertension, heart valve insufficiency, and hyperlipidemia. The resident had a physician order for Metoprolol Tartrate 12.5 mg twice daily, with specific instructions to hold the medication if the resident's heart rate was less than 55 beats per minute or if the systolic blood pressure (SBP) was less than 120. Review of the Medication Administration Record (MAR) for two months showed that nine nurses administered Metoprolol outside of these parameters on ten occasions, with the medication being given on days when the resident's SBP was below the ordered threshold. There was no documentation in the progress notes to explain why the medication was administered outside of the prescribed parameters on these dates. Interviews with nursing staff confirmed that Metoprolol was given in error when the resident's SBP was below the specified limit, and staff acknowledged that the medication should have been held according to the physician's order. The Director of Nursing also verified that the medication was not held as required and stated that nurses are expected to follow physician orders. The facility's policy on administering medication requires that medications be given in accordance with prescriber orders, including checking and verifying vital signs when necessary.
Failure to Implement Physician Orders and Notify Provider Leads to Resident Neglect and Hospitalization
Penalty
Summary
A deficiency occurred when facility nurses failed to implement a physician's order for urinalysis and urine culture (UA/CS) diagnostic testing for a resident who had exhibited blood-tinged urine. The order was entered into the system and marked as completed, but the test was never performed. The nurse who attempted to collect the specimen was unsuccessful, marked the order as completed in the Medication Administration Record (MAR), and did not document the refusal in a progress note or notify the physician or nursing management. There was no evidence that the failure to obtain the specimen or the resident's refusal was communicated to the oncoming nurse or to the provider, as required by facility policy. Over the following days, the resident's condition deteriorated, with documented fever and pain, but the missing diagnostic test was not identified by nursing staff, the unit manager, or the providers. The resident's family ultimately found the resident cold, clammy, and unresponsive, prompting emergency intervention and hospitalization. The resident was diagnosed with septic shock from a urinary tract infection (UTI) and required intensive care, including mechanical ventilation and life-sustaining measures. The facility only became aware that the UA/CS had not been performed when the resident's wife called to request the results after the resident was hospitalized. The facility did not conduct a thorough investigation into the possible neglect until prompted by the family's inquiry and the survey process. The incident was not reported to the State Agency as possible neglect until it was brought to the facility's attention during the survey. Interviews with facility staff, including the DON, NHA, and Risk Manager, confirmed that the failure to provide the ordered diagnostic testing and to notify the physician constituted neglect, as defined by the facility's own policies.
Failure to Implement Physician's Orders and Notify Provider Leads to Undiagnosed UTI and Septic Shock
Penalty
Summary
A deficiency occurred when nursing staff failed to implement a physician's order for a urinalysis with culture and sensitivity (UA/CS) for a male resident with multiple complex medical conditions, including hemiplegia, diabetes, and incontinence. The order was entered into the system after blood-tinged urine was observed, but the urine specimen was never collected. Nursing staff marked the order as completed in the Medication Administration Record (MAR) despite not obtaining the sample, and no progress note was made to document the failure or to notify the physician. The oncoming shift was not reliably informed, and the physician was not notified that the diagnostic test was not completed. The facility's process for tracking and following up on laboratory orders was not followed. Unit Managers and Advanced Practice Registered Nurses (APRNs) were expected to check lab logs and ensure completion, but the missing UA/CS was not identified or addressed. The resident's family later requested the test results and discovered the test had not been performed. Interviews with staff confirmed that the standard practice was to notify the physician if a specimen could not be collected, but this did not occur in this case. The resident's care plan included monitoring for signs and symptoms of urinary tract infection (UTI), but there was no care plan for actual urinary infection or blood in the urine. As a result of these failures, the resident's UTI went undiagnosed and untreated, leading to the development of septic shock. The resident became lethargic, developed a fever, and ultimately required emergency transfer to the hospital, where he was found to be in critical condition and required intensive care, including mechanical ventilation and IV antibiotics. The deficiency was determined to have placed the resident and others in Immediate Jeopardy due to the lack of timely diagnostic testing and appropriate medical intervention.
Failure to Include Indwelling Urinary Catheter in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop an individualized Comprehensive Care Plan that addressed the use of an indwelling urinary catheter for a resident who was admitted from an acute care hospital with multiple diagnoses, including a wedge compression fracture and a urinary tract infection (UTI). The resident was moderately cognitively impaired, required staff assistance for activities of daily living, and had an indwelling urinary catheter in place. Medical records indicated the resident was prescribed antibiotics for a UTI and required the insertion of a urinary catheter due to inability to urinate. Despite the Care Area Assessment (CAA) triggering the need for inclusion of the indwelling urinary catheter in the Comprehensive Care Plan, the care plan completed and revised during the resident's stay did not include any focus, goals, or interventions related to the catheter. The MDS Coordinator confirmed that the omission was an oversight, acknowledging that the catheter was not addressed in the care plan as required by facility policy and assessment findings.
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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.
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Nursing homes near Ocoee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orlando Health Center For Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare West Orange | 0.7 mi | ★★★★★ | 2 | 2 |
| Winter Garden Rehabilitation And Nursing Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Health Central Park | 3.4 mi | ★★★★★ | 0 | 0 |
| Metro West Nursing And Rehab Center | 4.4 mi | ★★★★★ | 6 | 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.