Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Orlando Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to keep call lights within reach for several residents. In one room, a nonverbal resident who communicated only with hand gestures had a call light hanging behind the bed on the headboard, out of reach. In another room, two residents—one asleep and one sitting on the edge of the bed waiting for lunch—also had call lights positioned behind their beds; one of them reported not knowing where the call light was and never receiving instructions on its use. Additionally, a resident with hemiparesis after a stroke, who required staff assistance for mobility, could not reach a call light that was attached too high on the right upper side of the bed sheet, and staff confirmed the placement was not accessible.
A resident with dementia and behavioral issues was physically abused when a CNA intentionally held the resident’s door shut, causing the resident’s fingers to be caught and injured. Despite the resident’s visible distress and bleeding, multiple staff members, including nurses and other CNAs, failed to intervene or assist. The incident resulted in lacerations to the resident’s hand and forearm, and the abuse was only confirmed after video footage was reviewed.
A resident with dementia and behavioral issues sustained a hand injury when a CNA closed a door on the resident, and multiple staff members witnessed the event or its aftermath but did not immediately report it as potential abuse. The incident was only discovered and reported to AHCA after management reviewed security footage the following day, resulting in a delay in protective measures and notification to authorities.
Surveyors identified multiple deficiencies in food service, including improper use of facial hair restraints by dietary staff, inadequate hand hygiene, failure to monitor and record food temperatures, improper storage and labeling of food items, failure to deliver ordered resident snacks, and failure to air-dry dishes and equipment. Dish machine temperature logs were inaccurate and did not meet required standards, and outdated or undated resident food was found in unit refrigerators.
Surveyors found that several residents requiring tracheostomy care did not have the necessary emergency equipment, such as Ambu bags and appropriately sized replacement tracheostomy tubes, at their bedside as ordered. In multiple cases, staff could not explain the absence of these supplies, and some respiratory equipment was not properly labeled or maintained. Additionally, a resident with a BiPAP order experienced a delay in receiving the device, and staff documented care as completed before the device was available, with no documentation of refusals or limited use. These deficiencies were confirmed through observations, staff interviews, and record reviews.
A staff member prepared croissant sandwiches with less than the required protein portion by not following the written recipe and relying on memory, resulting in sandwiches that did not meet the menu's nutritional requirements. The deficiency was identified when the CDM weighed the portions and found them insufficient, potentially affecting a large number of residents who consumed meals at the facility.
Surveyors identified ongoing deficiencies in Resident Rights, Resident Assessment, Quality of Care, Dietary, and Infection Control, with department heads unable to explain how the QAPI committee proactively addressed or monitored these issues. Staff interviews revealed a lack of sustained follow-up on past deficiencies, resulting in repeated non-compliance, such as continued failures in food safety protocols, in-room activities, and preadmission screenings.
Two residents with severe cognitive impairment and total dependence for eating were assisted with meals by staff who stood over them rather than sitting at eye level, contrary to facility policy and training. Staff acknowledged the importance of sitting to maintain dignity but did not consistently follow this practice, resulting in a lack of dignity during mealtime assistance.
A resident with cognitive capacity and multiple medical diagnoses was not given the opportunity to participate in her person-centered care plan after returning from a hospital stay. Due to an administrative oversight, no invitation was sent for the care plan meeting, and the meeting was not held, despite facility policy emphasizing resident involvement.
Two residents, both cognitively intact and with complex medical histories, were found in possession of medications at their bedside or on their nightstand without documented assessments, physician orders, or care plans authorizing self-administration. Facility staff confirmed that required assessments and orders for self-administration had not been completed, and could not provide a list of residents permitted to self-administer medications.
A resident with quadriplegia and intact cognition reported that his complaint about long call bell response times was not addressed by staff. Although two concerns were documented—one dietary and one about delayed CNA assistance—only the dietary issue was investigated, while the call bell grievance was not followed up or clarified, contrary to facility policy.
The facility did not update PASARR Level I and Level II evaluations for two residents after new major mental disorder diagnoses were identified. One resident with multiple mental health conditions and another with a history of schizophrenia, bipolar disorder, and other psychiatric diagnoses did not have their PASARR documentation updated to reflect these changes, despite facility policy requiring such updates. The Social Services Director acknowledged the oversight, and updates were only made after surveyor inquiry.
The facility did not ensure accurate completion and follow-up of PASARR screenings for two residents with mental health diagnoses. One resident's PASARR lacked required diagnoses, resulting in an inaccurate screening, while another resident who required a level II PASARR evaluation had no documentation of its completion or follow-up by the Social Services Director.
Surveyors found that several residents with cognitive and physical impairments, who required one-on-one in-room activities, were not provided with individualized activities as outlined in their care plans. Observations and record reviews showed a lack of documented and observed activity participation, despite staff claims that such activities were being provided.
The facility did not timely coordinate diagnostic imaging, laboratory testing, or specialty GI consults for two residents, resulting in delays and lack of documentation for ordered services. Additionally, wound care for another resident was not managed according to physician orders, with missed weekly wound measurements and incomplete documentation of treatments.
A resident with a history of stroke, left-sided weakness, and contractures did not consistently receive prescribed orthotic management, as staff failed to ensure the application and availability of a palm guard splint. Despite physician orders and care plans, the splint was often not applied, documentation was inconsistent, and staff were unclear about their responsibilities, resulting in the resident not receiving necessary care to maintain or improve range of motion.
A resident admitted with a PICC line did not receive appropriate care, as staff failed to flush the line, change the dressing, or assess the site. The EMAR lacked necessary orders for PICC maintenance, and a physician order for line removal was incorrectly marked as completed. Nursing staff confirmed the line was not maintained, and the DON acknowledged missing orders and lack of chart audit.
A resident with significant pain and multiple fractures did not receive prescribed Pregabalin for over a day due to pharmacy delivery delays. Nursing staff documented the delay but did not notify the physician or provide alternative pain relief, resulting in unmanaged severe pain.
A resident with a history of PTSD and childhood abuse did not receive trauma-informed care, as required by facility policy. Despite documented symptoms and a diagnosis of PTSD, there was no care plan addressing trauma history, and psychosocial assessments were inaccurate. Staff lacked awareness of the resident's triggers, and interventions were not consistently documented or communicated.
A resident with multiple complex conditions did not have a pharmacist's full medication recommendation implemented, as the order to hold Procrit for hemoglobin of 10 or more was omitted from the physician's orders. The DON confirmed the oversight, which was not in accordance with facility policy requiring timely follow-up on pharmacy recommendations.
A nurse prepared to administer an incorrect dose of Levetiracetam by placing two 750 mg tablets in a medication cup for a resident with seizures, instead of the ordered 750 mg and 500 mg tablets. The error, which would have resulted in a 1500 mg dose instead of the prescribed 1250 mg, was identified before administration after review of the physician's order and medication card.
A resident with diabetes and end stage renal disease did not consistently receive meals in accordance with her stated preferences for no bread and a small salad, despite these requests being documented on her meal tickets. Additionally, her dinner tray was routinely left in her room while she was out for dialysis, in violation of facility policy, and staff did not ensure she received a fresh meal upon her return.
Staff failed to follow infection control protocols by not providing hand hygiene to two dependent residents before meals and by not using required gowns and gloves during high-contact care for two residents with wounds. These lapses were observed during meal assistance and hygiene care, with staff acknowledging they did not follow established facility policies.
The facility failed to administer medications as per physician orders for two residents. One resident with type 1 diabetes and other conditions had multiple medications not documented as administered on a specific date. Another resident with type 2 diabetes and other conditions also had medications not documented as administered. The facility's policy requires immediate recording of medication administration, which was not adhered to.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves staff failing to ensure resident call lights were within reach in resident rooms and bathrooms/bathing areas. During observations on the D-wing, one resident in bed B by the window was awake, alert, but nonverbal and communicated only with hand gestures; this resident’s call light was found hanging behind the bed on the headboard, out of reach. The assigned CNA and the Unit Manager both confirmed the call light’s location behind the bed and acknowledged that staff should ensure call bells are within residents’ reach. In another room, one resident asleep in bed B by the window and another resident sitting on the edge of bed A waiting to eat lunch both had call lights hanging behind their beds on the headboards, not within reach. The resident sitting on the edge of the bed stated they did not know where the call light was and that staff had never provided instructions on its use. The CNA present confirmed both call bells were not within reach and acknowledged they should be left where residents can access them. A further resident, who had a history of stroke with inability to move the left side of the body and required staff assistance to move or get out of bed, reported being unable to reach the call light since the morning because it was attached too high on the right upper side of the bed sheet near the head. The CNA present confirmed this resident could not reach the call bell with the functioning right arm and acknowledged the call bell should be positioned within reach of that arm.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident with dementia and behavioral disturbances by intentionally holding the resident’s door shut, resulting in the resident’s fingers being caught in the door and causing bleeding and lacerations. The resident, who had significant cognitive and physical impairments, was on 1:1 supervision due to behavioral issues and a history of falls. Despite these needs, the CNA was observed on video holding the door closed while the resident struggled to open it, ultimately causing injury to the resident’s hand and forearm. The CNA was seen smiling at the camera during the incident, and other staff members in the vicinity did not intervene or respond to the resident’s distress. Multiple staff, including licensed nurses and other CNAs, were present during the incident but failed to take action to prevent or stop the abuse. Video footage confirmed that the CNA continued to hold the door shut even as the resident’s fingers were caught, and other staff either ignored the situation or did not provide assistance. Witnesses, including a visitor, observed the resident bleeding and attempting to get help, but nurses at the station did not respond until prompted by the visitor. The lack of immediate intervention by staff contributed to the resident’s harm and prolonged distress. The resident sustained injuries requiring hospital evaluation, including lacerations to the right hand and left forearm, though no fractures were found. The incident was not immediately reported accurately to the resident’s responsible party, and discrepancies in staff accounts were only clarified after video review. The facility’s policies required staff to report and prevent abuse, but these were not followed, as evidenced by the failure to protect the resident from physical harm and the lack of timely and appropriate staff response.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse to the Agency for Health Care Administration (AHCA) in a timely manner after an incident involving a resident with dementia and behavioral disturbances. The resident, who required substantial assistance for daily activities and was on 1:1 supervision due to combative behavior, was involved in an incident where a CNA was observed holding the resident's door closed, resulting in the resident's hand being caught in the door and causing bleeding. Multiple staff members, including nurses and CNAs, witnessed the event or its aftermath but did not immediately report it as potential abuse. The incident was only discovered by facility management the following day during a review of security camera footage, at which point the incident was reported to AHCA. The resident's medical record and care plans indicated significant cognitive and physical impairments, including a history of behavioral symptoms and dependence on staff for most activities of daily living. On the day of the incident, documentation and witness statements revealed that the resident became agitated, attempted to leave his room, and sustained injuries to his hand when the door was closed on him by the CNA. Despite visible injuries and the resident's distress, staff at the nurses' station did not intervene until prompted by a visitor, and there was a lack of immediate recognition or reporting of the event as abuse. Interviews with staff and review of video footage confirmed that several employees observed the CNA's actions and the resident's subsequent injury but failed to take prompt action or notify appropriate authorities as required by facility policy and federal regulations. The delay in reporting prevented timely protective measures for the resident and delayed notification to state authorities. The facility's own investigation and witness statements further corroborated that the incident was not reported until management became aware through camera review, highlighting a breakdown in the immediate reporting process for suspected abuse.
Deficiencies in Food Service Sanitation, Storage, and Distribution
Penalty
Summary
Multiple deficiencies were identified in the facility's food service operations, including improper use of facial hair restraints by dietary staff, inadequate hand hygiene, and failure to monitor and record food temperatures as required. Observations revealed that dietary aides did not wear facial hair restraints correctly, exposing facial hair while preparing and serving food. One aide was seen touching his face and adjusting his restraint, then handling food items without performing hand hygiene or changing gloves. The Assistant Dietary Manager confirmed that staff are required to wash hands and change gloves after touching their face. Additionally, cold food holding temperatures were not consistently recorded, and milk was found at a temperature above the required 41 degrees Fahrenheit. Milk cartons were also found stored at room temperature in a pantry, with the Unit Manager unable to explain why they were not refrigerated. The facility failed to deliver ordered resident snacks to all units as required, with individually labeled and dated nourishments remaining in the refrigerator instead of being distributed. The Certified Dietary Manager confirmed that these snacks were not delivered, which was contrary to facility policy and could impact residents' nutritional status. Further, improper storage and labeling of food items were observed, including raw meats in the walk-in refrigerator and freezer that were not dated as required by policy. Outdated and undated resident food items were found in multiple unit refrigerators, with staff acknowledging the importance of proper labeling and timely disposal but unable to explain why these procedures were not followed. Additional deficiencies included failure to air-dry dishes and equipment, as wet-nesting of bases was repeatedly observed, creating a moist environment that could promote germ growth. Review of dish machine temperature logs revealed that required wash and rinse temperatures were not met or accurately recorded for several months, and the logs did not indicate minimum temperature requirements or corrective actions. The dish machine was not operated according to manufacturer or policy specifications, and staff education on proper procedures was identified as lacking. These failures in food storage, preparation, distribution, and sanitation had the potential to affect all residents receiving meals at the facility.
Failure to Provide Required Respiratory Emergency Equipment and Treatments
Penalty
Summary
Surveyors identified multiple deficiencies related to the provision of safe and appropriate respiratory care for residents with tracheostomies and other respiratory needs. Several residents with tracheostomies did not have the required emergency equipment, such as Ambu bags and replacement tracheostomy tubes of the same size and one size smaller, at their bedside as ordered by physicians. In several cases, staff were unable to explain the absence of this equipment, and unit managers confirmed the missing supplies. For example, one resident with a tracheostomy had neither an Ambu bag nor the required replacement tracheostomy tubes at the bedside, and another had only partial supplies, lacking the smaller size tube as ordered. The facility's own policy required these supplies to be present and visible at the bedside, but observations revealed this was not consistently followed. In addition to missing emergency tracheostomy supplies, there were failures in the labeling and maintenance of respiratory equipment. For one resident, oxygen tubing, tracheostomy masks, and suction canisters were not labeled with the date of last change, and the required replacement tracheostomy set of one size down was not available due to supply issues. The Central Supply Director acknowledged not having ordered the necessary size for an extended period, and the DON confirmed the lack of appropriate supplies. Other residents were also found to have incomplete or incorrect emergency tracheostomy kits, with missing inner or outer cannulas or incorrect sizes, contrary to physician orders and facility policy. There were also deficiencies in the provision and documentation of respiratory treatments. One resident with an order for BiPAP therapy experienced a significant delay in receiving the device, and once delivered, staff were unclear on how to set it up or adjust settings. Documentation in the medical record indicated that care tasks related to the BiPAP were marked as completed even before the device was available, and refusals or limited use by the resident were not documented. Staff interviews revealed confusion about responsibilities for ordering and setting up respiratory equipment, and the facility lacked a specific policy for respiratory care beyond oxygen use.
Failure to Follow Menu Portion Sizes for Protein in Sandwich Preparation
Penalty
Summary
The facility failed to follow the prescribed menu and recipe portion sizes for croissant sandwiches, as observed during meal preparation. Specifically, a staff member prepared sandwiches using two slices of pre-sliced ham and one slice of pre-sliced cheese, which, when weighed by the Certified Dietary Manager (CDM), amounted to less than half of the required three-ounce protein portion specified in the menu and recipe. The staff member did not consult the written recipe, relying instead on memory from previous preparations, and was unaware that the pre-sliced items did not meet the required weight per portion. The CDM confirmed that the staff member did not check the recipe and emphasized the importance of following standardized recipes to ensure consistent nutrient provision for all residents, particularly those with nutritional challenges. The facility's policy on standardized recipes requires the use of recipes to maintain consistency in nutrient amounts per portion and assigns responsibility to the Food Service Manager to monitor compliance. This deficiency had the potential to affect 263 residents who consumed meals at the facility.
Repeated Non-Compliance Due to Ineffective QAPI and Lack of Sustained Improvement
Penalty
Summary
The facility failed to demonstrate sustained performance improvement in addressing previously identified quality deficiencies, resulting in repeated non-compliance across multiple regulatory areas. During the most recent recertification survey, surveyors found ongoing issues in Resident Rights, Resident Assessment, Quality of Life, Quality of Care, Dietary, and Infection Control. Department heads, including the Food Services Manager, Activities Director, and Social Worker, were unable to provide specific details on how the Quality Assessment and Performance Improvement (QAPI) committee proactively addressed or monitored these deficiencies to prevent recurrence. For example, the Food Services Manager and Administrator could not explain why dietary staff continued to violate food safety protocols, and the Activities Director was unable to account for repeated failures to provide 1:1 in-room activities for certain residents as required by their care plans. Interviews revealed that while some staff were aware of past deficiencies and had implemented Performance Improvement Plans (PIPs), there was a lack of ongoing monitoring and follow-up to ensure that improvements were sustained. The Social Worker, for instance, was solely responsible for reviewing preadmission screening assessments for a large number of residents and did not seek additional support, despite repeated deficiencies in this area. Similarly, the Administrator and DON acknowledged that current issues with nursing care, such as failures in PICC line management, mirrored those cited in previous surveys, but could not detail how QAPI ensured departments were preventing repeated deficiencies. The report highlights that the facility's approach to quality improvement was largely reactive, with department heads and leadership unable to demonstrate proactive strategies or sustained monitoring to address and prevent repeated non-compliance. The lack of detailed, department-specific QAPI initiatives and insufficient follow-through on previously identified issues contributed to ongoing regulatory deficiencies in key areas affecting resident care and services.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Staff failed to ensure that two residents with severe cognitive impairment and total dependence for eating were afforded dignity during mealtimes. Both residents had care plans indicating total dependence on staff for eating and other activities of daily living. During meal observations, staff members, including a CNA and a physical therapist, were seen standing while assisting these residents with their meals rather than sitting at eye level. One CNA acknowledged she was supposed to sit while feeding but did not do so because a chair was unavailable, and the physical therapist was unaware of the requirement to sit while assisting with meals. Both staff members later confirmed their understanding that sitting was necessary to maintain resident dignity, but did not follow this practice during the observed meals. The facility's policy required nursing staff to assist residents in need during mealtimes, and the Assistant Director of Nursing confirmed that CNAs were trained on the importance of sitting while assisting with meals. Despite this, staff did not consistently follow the policy, and in at least two instances, residents were assisted with eating while staff stood over them, rather than sitting at their level. This failure to follow established protocols resulted in a lack of dignity for the residents during mealtime assistance.
Resident Not Provided Opportunity to Participate in Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident with the opportunity to participate in the development and implementation of her person-centered plan of care. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15 and had diagnoses including soft tissue disorders, shortness of breath, and myositis, reported not being invited to care plan meetings. Review of the medical record and interviews confirmed that while invitation letters for care plan meetings were typically sent, an invitation for the May meeting was not provided after the resident returned from a hospital stay. The invitation had been marked as 'D/C' (discharged) when the resident was transferred to the hospital, and no new invitation was issued upon her readmission. Facility policy and the resident handbook both emphasized the importance of resident participation in care planning, including holding meetings at times convenient for the resident and encouraging input from the resident and family. Despite these policies, the resident was not given the opportunity to participate in the care planning process following her return to the facility, as the scheduled meeting was not held and no alternative arrangements were made.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess and authorize residents for self-administration of medications as required by policy and physician orders. One resident with a history of dysphagia, sepsis, severe protein-calorie malnutrition, and hypertensive heart disease, who was cognitively intact, was found with multiple medications at his bedside, which he reported using as needed for pain since admission. There was no physician order or care plan assessment permitting this resident to self-administer medications. The unit manager confirmed the medications were present and removed them, stating that the facility would need to administer the medications per physician orders. Another cognitively intact resident with multiple diagnoses, including muscle disorders, diabetes, sepsis, and COPD, was found with a medicine cup of pills on his nightstand. The resident stated a nurse had given him the cup of pills, and the nurse later acknowledged uncertainty about whether the resident was assessed for self-administration. There was no documentation of an assessment, physician order, or care plan for self-administration for this resident. Facility staff confirmed that assessments and orders were required but had not been completed, and they could not provide a list of residents authorized to self-administer medications.
Failure to Address Resident Grievance Regarding Call Bell Response
Penalty
Summary
A resident with quadriplegia, multiple muscle contractures, and abnormal posture, who was cognitively intact, reported that his care concerns were not being addressed by staff. He specifically mentioned making a complaint about long call bell response times, stating that there were several hours of delay, but this issue had not been resolved. Review of his medical record and grievance documentation revealed that two concerns were reported: one related to dietary issues and another regarding difficulty finding help from CNAs and long call bell response times. The facility's Grievance/Concern report showed that only the dietary concern was addressed, with no documentation or investigation into the complaint about call bell response times. The Social Services Director confirmed that both concerns should have been treated as separate grievances and that the issue regarding call bell wait times was not investigated or clarified further. Facility policy required the Social Services representative or Grievance Official, in collaboration with the Nursing Home Administrator, to assign concerns to the appropriate department and monitor resident satisfaction, but this process was not followed for the call bell grievance.
Failure to Update PASARR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The facility failed to update and coordinate the Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluations for residents who had new or existing major mental disorder diagnoses. One resident, who had been admitted with diagnoses including dementia, epilepsy, depression, anxiety, and psychotic disorder, was noted during a psychologist session to have a depressed mood and feelings of being overwhelmed. Despite these findings and changes in mental health status, there was no evidence in the medical record that the Level I PASARR had been updated until prompted by surveyors, with the most recent update occurring only after the issue was identified. Another resident, with a history of adjustment disorder, anxiety disorder, bipolar disorder, schizophrenia, and dementia, exhibited behaviors such as verbal abuse, combativeness, and catatonia. The resident's PASARR documentation did not reflect new diagnoses of schizophrenia and adjustment disorder, and only listed bipolar disorder. The Social Services Director acknowledged responsibility for updating PASARR forms and was aware that the resident should have been re-screened after the new diagnoses were added, but this was not done. The facility's policy required PASARR reviews prior to admission and upon new diagnoses, but these procedures were not followed for the residents in question.
Failure to Complete and Follow Up on PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to properly complete and follow up on Preadmission Screening and Resident Review (PASARR) requirements for two residents with mental disorders or intellectual disabilities. For one resident with vascular dementia, major depressive disorder, and other significant medical conditions, the Minimum Data Set (MDS) assessment indicated cognitive impairment and depression. However, the PASARR form on file did not list any diagnoses in the required section, resulting in an inaccurate screening. The Social Services Director acknowledged the omission and confirmed that the PASARR was incorrect at the time of admission. For another resident with schizoaffective disorder, bipolar type, anxiety disorder, and a history of other mental and behavioral disorders, the level I PASARR screening indicated the need for a level II evaluation. Despite this, there was no documentation that a level II PASARR evaluation was completed or that any follow-up was attempted with the contractor responsible for the screening. The Social Services Director verified that the required level II PASARR was not completed and that no evidence of follow-up existed in the resident's record.
Failure to Provide Resident-Centered In-Room Activities
Penalty
Summary
The facility failed to provide a resident-centered activities program to meet the needs of residents who required one-on-one in-room activities. During a five-day survey period, five residents residing on a locked unit were observed, and no activities were provided to them during the observed hours. These residents had documented cognitive and physical impairments, including dementia, encephalopathy, mood disorders, schizophrenia, repeated falls, and in some cases, tracheostomy and gastrostomy status. Their care plans specified the need for staff-assisted in-room activities, such as reading, watching television, music, socializing, and sensory stimulation, with staff visits scheduled one to two times per week. Record reviews for these residents revealed a lack of documentation of individual in-room activities for the month prior to the survey, with most residents having no recorded participation in any activities. Observations confirmed that these residents were not engaged in any activities during the survey period, and staff were not seen providing or assisting with activities as outlined in the residents' care plans. In one case, a resident's television was only on for one day out of five, and another resident had only one documented in-room activity in the past 30 days. The Activity Director stated that activities were provided daily on the locked unit and that in-room activities were performed and documented one to two times per week. However, she was unable to explain the lack of observed activities and documentation for the residents in question during the survey period. This discrepancy between the care plans, staff statements, and actual practice led to the deficiency in providing individualized activities for residents requiring in-room engagement.
Failure to Coordinate Diagnostic, Specialty, and Wound Care Services
Penalty
Summary
The facility failed to provide timely coordination of care for diagnostic imaging, laboratory services, and specialty consultations for two residents. One resident with a history of volvulus and abdominal distension experienced a delay of one week in scheduling a recommended CT scan after a GI specialist noted a distended abdomen and advised imaging to rule out obstruction. Both the resident and her family reported ongoing abdominal enlargement without explanation, and the unit manager could not account for the delay in following up on the specialist's recommendation. Another resident with malignant brain cancer, dysphagia, and significant weight loss had multiple physician orders for fecal occult blood testing and a GI consult over a two-month period. Despite repeated orders, there was no documentation of completed stool tests or a GI consult, and staff were unable to locate test results or confirm that the consult had occurred. The DON and APRN confirmed the absence of results and consult documentation, and the GI specialist did not recall providing a consultation for the resident. Additionally, the facility failed to obtain physician orders for wound care and did not complete weekly wound measurements for a resident with multiple abrasions. Documentation showed gaps of up to two weeks without wound measurements for abrasions on the right gluteal area, left ischial tuberosity, and penis. There were no physician orders for the right gluteal wound, and the prescribed treatment for the left ischial tuberosity was not followed. Nursing staff could not provide details about the wound care products used, and the DONs confirmed that weekly wound measurements were not consistently performed, with no documented refusals from the resident.
Failure to Provide Consistent Orthotic Management for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services related to the management and application of orthotic devices for a resident with limited range of motion (ROM) and reduced mobility. The resident, who had a history of stroke with left-sided weakness and paralysis, type 2 diabetes, and contractures, had physician orders and care plans in place for the use of a palm guard splint to be worn for up to three hours daily. Despite these orders, observations revealed the resident was not wearing the splint on multiple occasions, and the resident reported that her sister had taken the splint home to wash it due to odor, with no clear process in place for cleaning within the facility. The resident also stated she was not receiving restorative nursing services and sometimes had to apply the splint herself, which was difficult and painful. Interviews with staff indicated confusion and lack of clarity regarding responsibility for applying the splint. Certified Nursing Assistants (CNAs) and nurses were both identified as responsible for ensuring the splint was applied, but documentation was inconsistent. The Treatment Administration Record (TAR) showed nurses signed off on the splinting task daily, but CNA documentation frequently marked the task as not applicable, and some days were left blank. Staff interviews revealed that splint application was often not verified before documentation, and some staff were unaware of the resident's need for a splint or that the splint was not present in the room. Further review of therapy and nursing records showed that the resident was not currently on therapy caseload, and the Restorative Nursing Program (RNP) was not active in the facility. Although therapy had provided initial training and recommendations for splint use, ongoing management was left to nursing staff, who did not consistently ensure the splint was available or applied as ordered. There was no documentation of resident refusal to wear the splint, and the care plan for refusal was only recently created without supporting evidence. This lack of coordination and follow-through resulted in the resident not receiving the prescribed orthotic management to prevent worsening of contractures and promote skin integrity.
Failure to Provide Care and Services for Resident's PICC Line
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Peripherally Inserted Central Catheter (PICC) line. Upon admission from the hospital, the resident's transfer form did not indicate the presence of an IV line, but facility staff documented the existence of a PICC line in the resident's right arm. The resident reported that the facility did not use the PICC line for medication administration, nor did staff flush the line or change the dressing. Observation confirmed that the PICC dressing was dated prior to the resident's admission, indicating it had not been changed during her stay. There were no physician orders in the electronic medication administration record (EMAR) for dressing changes, saline flushes, or site assessments for the PICC line. Further review revealed that a physician order to remove the midline was marked as completed in the EMAR, despite the PICC line not being removed. Nursing staff confirmed that the PICC line had not been flushed or assessed, and the dressing had not been changed as required. The Director of Nursing acknowledged that the admitting nurse failed to enter necessary orders for the PICC line and that the resident's chart had not been audited to ensure proper care orders were in place. As a result, the facility did not provide the required care and monitoring for the resident's central line.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A resident with multiple complex diagnoses, including polyneuropathy, spinal fusions, and several fractures, was admitted to the facility and had a physician's order for Lyrica (Pregabalin) 100 mg every eight hours for pain management. Despite this order, the resident did not receive the prescribed pain medication for approximately 36 hours, missing four doses, because the facility was waiting for the pharmacy to deliver the medication. Nursing progress notes documented the delay, but there was no evidence that the physician was notified about the missed doses or that an alternative pain medication was offered during this period. The resident reported severe pain, rating it as nine or ten out of ten, and stated that the pain prevented him from sleeping. Nursing staff confirmed the medication was not available and had not been administered as scheduled, despite documentation on the medication administration record indicating otherwise. The unit manager stated that the expectation was for nurses to reorder medications before running out to prevent interruptions, which did not occur in this case, resulting in a failure to provide timely and appropriate pain management.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a documented history of post-traumatic stress disorder (PTSD) and childhood abuse. The resident was admitted with multiple diagnoses, including PTSD, and her medical record indicated ongoing symptoms such as nightmares, flashbacks, and hypervigilance, particularly at night. Despite these documented issues, the electronic medical record did not include a care plan specifically addressing her trauma history or PTSD, and psychosocial assessments inaccurately stated that she had never been diagnosed with PTSD or experienced a life-altering event. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's trauma history and specific triggers. While some staff were aware of the PTSD diagnosis, there was no written documentation or care plan to guide staff in providing trauma-informed care or to ensure that interventions, such as assigning only female CNAs, were consistently implemented. The Social Services staff were either unaware of the PTSD diagnosis or not informed of the details, and acknowledged that the psychosocial assessments were inaccurate and that no trauma-informed care plan had been developed or implemented. The facility's own policy required the development of a comprehensive, person-centered care plan for residents with trauma histories, including identification of triggers and appropriate interventions. However, this was not done for the resident in question, and staff were not provided with the necessary information to avoid retraumatization. The deficiency was identified through observation, interview, and record review, confirming that the facility did not meet its own standards or regulatory requirements for trauma-informed care.
Failure to Implement Pharmacist Medication Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to fully implement a pharmacist's medication recommendation for a resident with multiple complex diagnoses, including encephalopathy, type II diabetes mellitus, history of liver transplant, sepsis, atrial fibrillation, and acute kidney failure. The pharmacist had reviewed the resident's medication regimen and recommended changing the route of administration for Procrit from intramuscular to subcutaneous and to hold the medication if the resident's hemoglobin was 10 or more. While the route of administration was updated in the physician's orders, the instruction to hold Procrit for hemoglobin of 10 or more was not added. The Director of Nursing (DON) acknowledged responsibility for ensuring pharmacy recommendations were addressed and confirmed that the recommendation regarding the hemoglobin threshold was missed. The facility's policy required that all pharmacist recommendations be followed up on within 30 days to ensure appropriate action. This oversight resulted in the resident's medication orders not fully reflecting the pharmacist's recommendations as required by facility policy.
Medication Administration Error: Incorrect Levetiracetam Dosage Prepared
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer Levetiracetam to a resident for seizure control. The physician's order specified a dose of 1250 mg every 12 hours, to be given as one 750 mg tablet and one 500 mg tablet. During medication administration, the RN placed two 750 mg tablets in the medication cup, totaling 1500 mg, which exceeded the prescribed dose. The error was identified before the medication was given, after the RN was prompted to review the order and the medication card, which detailed the correct tablet combination. The facility's medication administration guidelines require verification of the medication three times: when pulling the medication from the cart, when preparing the dose, and before administration. Both the unit manager and the executive director of nursing stated their expectations that nurses administer medications exactly as ordered and are able to calculate correct dosages. The incident was observed during a medication pass and confirmed through interviews and record review.
Failure to Honor Food Preferences and Meal Timing for Dialysis Resident
Penalty
Summary
The facility failed to honor a resident's food preferences and accommodate alternate meal times for a resident undergoing renal dialysis. The resident, who had diagnoses including type II diabetes mellitus, heart failure, and end stage renal disease with dialysis, reported that despite informing two dietitians of her preference for no bread and a small salad at lunch and dinner, she continued to receive bread and often did not receive the requested salads. Meal tickets reflected her preferences, but observations showed that her trays did not consistently match these requests. For example, her lunch tray did not include the salad and dressing as indicated, and her dinner tray included bread products despite her request for no bread. Additionally, the resident's dinner tray was routinely left at her bedside while she was out for dialysis, contrary to facility policy, which required that trays not be left unattended in resident rooms. Staff interviews confirmed that the meal was left for her to eat upon return, sometimes hours later, and that the system for ensuring food preferences and proper meal delivery was not consistently followed. The dietary and nursing staff acknowledged the resident's requests and the discrepancies, and the facility's policies outlined procedures that were not adhered to in this case.
Failure to Follow Infection Control Practices During Resident Care and Meals
Penalty
Summary
Facility staff failed to implement proper infection prevention and control practices during resident care and meal assistance. Two residents with severe cognitive impairment and total dependence on staff for activities of daily living were observed during lunch. A physical therapist assisted one resident with feeding immediately after providing physical therapy, without removing gloves or performing hand hygiene for herself or the resident. Additionally, a certified nursing assistant assisted the other resident with her meal without providing hand hygiene to the resident beforehand. Both staff members acknowledged their lapses, with the physical therapist stating she did not think about hand hygiene and the CNA admitting she forgot to wash the resident's hands before the meal. Further deficiencies were observed regarding the use of enhanced barrier precautions for residents with wounds. One resident with a sacral wound had an enhanced barrier precautions sign posted, indicating the need for gowns and gloves during high-contact care. However, two CNAs provided pericare and hygiene care without donning gowns, later confirming they forgot and could not find gowns nearby. Another resident with multiple wounds received hygiene care and a transfer from his wheelchair to bed by two CNAs who also failed to wear gowns, despite facility policy requiring enhanced barrier precautions for residents with wounds. Facility policies required hand hygiene for staff and residents before meals and the use of gowns and gloves during high-contact care for residents with wounds. These policies were not followed during the observed incidents, as confirmed by staff interviews and direct observation. The failures included both a lack of hand hygiene and improper use of personal protective equipment during care activities for residents at risk.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as per physician orders and according to professional standards of practice for two residents. Resident #2, who was cognitively intact with a BIMs score of 15, had multiple medications prescribed for conditions including type 1 diabetes, insomnia, depression, and anxiety. On August 15, 2024, the Medication Administration Record (MAR) for several medications, including Doxepin, Melatonin, Remeron, Trazadone, Buspirone, Cefdinir, Celecoxib, Insulin Glargine, Insulin Lispro, Methocarbamol, and Sodium Chloride, was found to be blank with no documentation of administration or reasons for non-administration. Similarly, Resident #4, also cognitively intact with a BIMs score of 15, had medications prescribed for type 2 diabetes, epilepsy, major depressive disorder, and hypertension. On August 7, 2024, the MAR for Insulin Glargine, Pantoprazole, and Insulin Lispro was blank, with no documentation of administration or reasons for non-administration. The Executive Director of Nursing confirmed the blanks in the MARs and acknowledged the lack of documentation. The facility's policy requires medications to be administered in accordance with prescriber orders and recorded immediately after administration, which was not followed in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Orange Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Delaney Park Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Westminster Towers | 1.6 mi | ★★★★★ | 0 | 0 |
| Guardian Care Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Commons At Orlando Lutheran Towers | 2.2 mi | ★★★★★ | 1 | 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.