Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Rehabilitation Center Of Orlando during CMS and state inspections, most recent first.
Surveyors found multiple environmental deficiencies, including two East Wing shower rooms with stained, deteriorated grout and tiles, and a toilet containing dark brown standing liquid with heavy staining that remained unaddressed on recheck. On one wing, several resident rooms had warped and broken entrance doors with sharp edges, missing or damaged closet doors, cracked baseboards, unfinished drywall patchwork, wall holes, scuffed bathroom doors, and stained ceilings with black speckles. A resident reported that a wheelchair had recently ripped the room door and that the closet door had been broken for a long time, while a family member reported holes and ceiling stains and noted that only another wing had been renovated. In a back hallway, floor tiles around a drain were missing, mismatched, cracked, and eroded, exposing subfloor and creating uneven flooring. The Maintenance Director, working largely alone and relying on CNAs to submit work orders, confirmed the damage but maintenance logs showed no work orders or repairs for these issues, despite policies requiring preventive maintenance and housekeeping oversight.
Surveyors found that the facility failed to implement its QAPI program sufficiently to sustain compliance with homelike environment requirements, resulting in a repeat F584 deficiency. Previously, the facility had been cited for not providing a homelike environment and responded by focusing staff education and monitoring mainly on dining room conditions, such as centerpieces, without extending oversight to other areas like shower rooms and resident rooms. The NHA reported significant leadership turnover, including multiple DON changes, a new Maintenance Director, and gaps in staffing coordination, along with ongoing housekeeping challenges, which coincided with inadequate auditing, monitoring, and tracking of performance needed to maintain a homelike environment throughout the facility.
A CNA was observed wearing gloves while standing by a medication cart in a hallway, conversing with a nurse and holding a soiled bag, then walking down the hallway toward a soiled utility room and removing only one glove while keeping the other on when entering the room. In a subsequent interview, the CNA admitted awareness that gloves should not be worn in hallways and described being distracted. The unit manager and DON both confirmed that wearing gloves in hallways is an infection control concern and that gloves are to be removed inside a resident’s room before exiting, contrary to the facility’s infection prevention and control policy.
The facility did not ensure a homelike dining environment, as residents in both main and west wing dining rooms were observed eating meals from trays, with dishes not removed and tables lacking decorations or tablecloths. Staff interviews confirmed these practices were routine, and facility leadership acknowledged the absence of a policy or consistent approach to creating a homelike setting.
A nurse failed to administer prescribed antihypertensive and diuretic medications to a resident with multiple chronic conditions, despite physician orders and appropriate blood pressure readings. The nurse withheld medications without justification and did not follow protocol after a medication was dropped and unavailable, resulting in a medication error rate of 10.71%.
Surveyors found that food items in nourishment refrigerators on both nursing units were not consistently labeled or dated, and expired foods were not discarded as required. Multiple undated and expired items, including thickened juice, cheese, bologna, nutritional supplements, and resident leftovers, were observed. Staff confirmed that nursing was responsible for labeling and dating, while dietary was responsible for discarding outdated items, in accordance with facility policy.
Staff were repeatedly observed disposing of trash in facility dumpsters without closing the lids and leaving rubbish scattered around the dumpster area, despite being aware of the requirement to keep lids closed and the area clean to prevent pests. The facility's policy assigned responsibility for maintaining the dumpster area to the CDM and Director of Maintenance, but these procedures were not consistently followed, potentially affecting all residents.
The facility was cited for repeat deficiencies in both its QAPI oversight and medication error rate, as the QAPI committee did not sustain prior improvement measures or provide sufficient auditing and oversight. Despite monthly meetings and departmental audits, the committee failed to prevent recurrence of issues, with recent administrative and ownership changes possibly contributing to a lapse in focus.
A CNA was observed standing while assisting a resident with severe cognitive impairment and multiple medical conditions during meals, rather than sitting as expected to promote dignity. Facility leadership confirmed that staff were expected to sit while assisting with meals to ensure residents felt valued and not rushed, although no formal policy was in place.
The facility failed to address and resolve concerns raised by the Resident Council, including long call light response times, late meal deliveries, and insufficient ice availability. Despite repeated complaints from January to July 2024, the administration provided no detailed updates or resolutions, leaving residents feeling ignored. The facility's policy mandates prompt action on grievances, but the Administrator admitted to not paying sufficient attention to these issues.
The facility failed to implement policies effectively, leading to deficiencies in handling Resident Council grievances and abuse reporting. Despite a Plan of Correction approved by the QAPI committee, similar issues were noted in a previous survey. The Administrator, new to the role, expressed surprise at the findings.
A resident with dementia and requiring a Creole interpreter was allegedly verbally abused by a CNA, as reported by her daughter. The facility failed to report this allegation to State agencies as required. The Social Services Director did not consider it abuse due to the resident's impaired cognition, and the Administrator was initially unaware of the grievance. The facility's policy required immediate reporting of abuse allegations, but the incident was not reported, and the investigation was undocumented.
Environmental Disrepair and Unsanitary Shower Areas Compromise Homelike Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident care areas and rooms. Surveyors observed that two shower rooms on the East Wing were in deteriorated and unsanitary condition. In one shower room, walls and grout were discolored and stained, grout at the base of the walls was cracked, deteriorated, and separated, and the 2x2 inch floor tiles were worn, uneven, damaged, and included missing and mismatched tiles. In the second shower room, the toilet bowl contained dark brown standing liquid with heavy staining consistent with prolonged buildup, poor drainage, or inadequate cleaning and maintenance, and this condition remained unchanged when rechecked the following day. The Housekeeping Director and Environmental Services District Manager, after reviewing photographs, acknowledged degraded or missing grout and apparent growth on the walls, and the Housekeeping Director stated that housekeepers entered the shower rooms daily but had not reported the clogged toilet. Additional environmental deficiencies were identified in resident rooms on the [NAME] Wing and in the West Wing back hallway. In one resident room, the lower portion of the entrance door was warped and broken with sharp edges, and the bottom panel was lifted approximately eight inches; the closet door was chipped, uneven, and did not close properly. Another room had missing closet doors, a cracked baseboard near the bathroom door measuring approximately three to five inches, scratches on the bathroom door, and unfinished drywall patchwork near the bathroom entrance and window. A third room had deteriorated wall surfaces along the lower portion near the floor, unfinished drywall patchwork with visible spackling, and a cracked baseboard near the bathroom door measuring approximately two to four inches. In another room, the baseboard near the bathroom door was cracked two to four inches wide, the bathroom door had multiple scuff marks, and four to six penny-sized holes were present on the wall above the B-side dresser, with black speckles on the ceiling above bed B and in the bathroom. Surveyors also found that the back hallway floor on the [NAME] Wing around a drain was in poor repair, with multiple missing tiles, mismatched and patchworked tiles, visible cracked and broken tile edges, exposed subfloor material, erosion, and uneven flooring. Interviews revealed that a resident reported the entrance door damage occurred when a roommate’s wheelchair got caught in it a few days earlier and that the closet door had been broken for a long time. A family member reported holes in the wall and stains on the bedroom and bathroom ceilings and stated that while the East Wing had been renovated, nothing had been done on the [NAME] Wing. The Maintenance Director, who had been working alone for several weeks and relied on CNAs to enter work orders, confirmed the damaged doors, patchwork flooring, and deteriorated room conditions and stated he had been unaware of the missing tiles in the shower floor. Review of maintenance logs from November 2025 through the survey date showed no documented work orders or repairs for the deteriorated shower rooms, unsanitary toilet, damaged resident room doors and walls, or hallway flooring, despite facility policies requiring ongoing inspections, preventive maintenance, and housekeeping to promote a sanitary, safe, and comfortable environment.
Failure to Sustain QAPI Oversight for Homelike Environment Requirements
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its Quality Assurance and Performance Improvement (QAPI) program so that previously identified quality concerns were comprehensively monitored and sustained. Survey history showed a prior deficiency under F584 for failure to provide a homelike environment during the last recertification survey. The facility’s Plan of Correction at that time focused on re-educating staff about maintaining a clean and homelike dining environment, including providing centerpieces, and on educating new and agency staff during orientation. During the current survey, a repeat deficiency under F584 was identified, demonstrating that the earlier improvement efforts were not adequately monitored or sustained. The Administrator reported that the prior homelike environment concern had been interpreted narrowly as an issue with missing centerpieces in the dining room, and the QAPI-driven Plan of Correction focused mainly on common areas related to the dining experience. The Administrator acknowledged that the homelike environment was not evaluated or monitored throughout the facility, and that shower rooms and residents’ rooms were not included in the POC or auditing process. She also described significant turnover and operational challenges, including three DON changes in six months, a new Maintenance Director, and periods without a Staffing Coordinator, as well as ongoing housekeeping issues and limited progress in that area. The facility’s written QAPI policy stated that the program was intended to be comprehensive and data-driven, addressing all care and services and ensuring ongoing monitoring and sustained improvement, but the survey findings showed this was not carried out in practice for the homelike environment requirement.
Improper Glove Use in Hallway Breaches Infection Control Practices
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices regarding the use of personal protective equipment (PPE) on the West Wing. During observation, a CNA was seen standing by a medication cart in the hallway talking with a nurse while holding a soiled bag and wearing gloves on both hands. After several minutes, the CNA walked down the hallway toward the soiled utility room, removed the glove from her left hand but kept the glove on her right hand while still holding the soiled bag and then entered the utility room. In an interview immediately afterward, the CNA acknowledged she had been wearing gloves in the hallway, confirmed she knew she was not supposed to wear gloves in the hallway because it was a break in infection control practice, and stated she had gotten distracted. The Unit Manager confirmed that staff should not wear gloves in the hallways because it was an infection control concern and that gloves must be removed inside the resident’s room before exiting, and the DON also confirmed that the CNA walking down the hallway wearing gloves was an infection control concern. Review of the facility’s Infection Prevention and Control Program policy showed it was intended to prevent the development and transmission of communicable diseases and infections, which was not followed in this instance.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents in both the main and west wing dining rooms. Observations revealed that residents were served meals on trays, with dishes not removed and placed on the tables, despite the presence of tablecloths in the main dining room. In the west wing dining room, tables were bare, lacking both tablecloths and centerpieces, and residents consistently ate from trays. Staff interviews confirmed that the practice of not removing dishes from trays and the absence of table decorations was routine, particularly in the west wing dining room. Further interviews with facility staff, including a CNA and the Business Office Manager, indicated a lack of clarity and consistency regarding dining room setup and the provision of a homelike environment. The Administrator acknowledged the ongoing issue of residents eating from trays and the lack of decorations, stating that previous centerpieces had been discarded and there was no specific policy addressing the creation of a homelike dining environment. The Unit Manager also recognized the importance of making the environment homelike, as the facility serves as the residents' home.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer medications as ordered for a resident with multiple diagnoses, including hypertension, COPD, schizophrenia, type 2 diabetes, chronic pulmonary edema, and chronic hepatitis C. During a medication pass, the nurse withheld two antihypertensive medications, Losartan Potassium and Sotalol HCl, despite the resident's blood pressure being above the physician-ordered parameters for holding the medications. The nurse did not provide an explanation for this decision, and the Director of Nursing confirmed that the medications should not have been held under the circumstances. Additionally, the nurse failed to administer the resident's prescribed dose of Furosemide after dropping the last available tablet into the medication cart drawer. The nurse did not attempt to retrieve the medication from another source, nor did she contact the pharmacy or physician for further instructions, as required by facility policy. These actions resulted in three medication errors out of 28 opportunities, leading to a medication error rate of 10.71%, which exceeds the acceptable threshold.
Failure to Label, Date, and Discard Outdated Food Items in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items stored in the snack/nourishment refrigerators on both nursing units were properly labeled and dated with open and use by dates. During a tour of the west wing nourishment room, the Unit Manager confirmed the presence of multiple undated and unlabeled food items, including thickened juice, cheese, bologna, containers of peaches and applesauce, unidentified leftover resident food, and salami. The Unit Manager stated that nursing staff were responsible for labeling and dating food items when received or opened, while the dietary department was responsible for monitoring and discarding expired or outdated resident leftovers. In the east wing nourishment room, the Certified Dietary Manager verified that the refrigerator contained undated cartons of thickened water and nutritional supplements, as well as several expired or unlabeled food items. These included a sandwich and a bag of food items dated several weeks prior, an unlabeled loaf of bread, a plastic container of leftover chicken dated over a month prior, and other resident-labeled containers of food that were also significantly outdated. The Assistant Director of Nursing confirmed the responsibilities of nursing staff and the dietary department regarding labeling, dating, and discarding food items. The facility's policy required all food items held for residents to be labeled with the resident's name, food item, and use by date, and for nursing staff to discard perishable foods on or before the use by date.
Improper Garbage Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of garbage and maintain the cleanliness of the dumpster area, as observed on multiple occasions. Rubbish was found scattered around the three dumpsters, and several staff members, including a housekeeper, dietary aides, and a laundry aide, were observed disposing of trash without closing the dumpster lids. Staff acknowledged awareness of the requirement to keep lids closed to prevent pests and contamination but did not consistently follow this protocol. The Certified Dietary Manager (CDM) indicated that housekeeping was responsible for maintaining the area, and the Environmental Services Regional Manager confirmed the importance of keeping the area clean and lids closed. The facility's policy on garbage disposal required that all garbage be disposed of safely and efficiently, with the CDM and Director of Maintenance responsible for ensuring the area around the dumpsters remained free of debris. Despite this policy, repeated failures to close dumpster lids and maintain the area were observed, with staff admitting to not following procedures even though they understood their importance. No specific residents were directly involved or affected at the time of the observations, but the deficiency had the potential to impact all 112 residents in the facility.
Repeat Deficiencies in QAPI Oversight and Medication Error Rate
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee effectively conducted performance improvement activities to sustain prior corrective measures. Despite having a QAPI policy that required ongoing actions, measurement of success, and tracking of performance, the facility was cited for repeat deficiencies in medication error rate (F759) and QAPI processes (F867) during the current and previous recertification surveys. The report notes that there was insufficient auditing and oversight to prevent recurrence of these deficiencies, indicating that the QAPI committee did not maintain adequate follow-up or monitoring to ensure sustained improvement. The Administrator confirmed that the QAPI committee met monthly and reviewed departmental audits, with Performance Improvement Plans (PIPs) developed for identified concerns. However, the Administrator, who had only recently returned to the facility, was unable to specify where the process failure occurred. She acknowledged that recent changes in ownership and administration may have contributed to a loss of focus, but also recognized that the performance improvement process should have continued regardless of staff changes. The repeat citations and lack of sustained improvement measures were directly observed by surveyors during the current survey.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while assisting a resident with eating in the main dining room. The resident in question had a history of Parkinson's disease, diabetes mellitus type II, seizures, depression, anxiety, and a psychotic disorder, and required maximum to total assistance for eating due to deficits in activities of daily living and a risk for nutritional decline. The resident also had severe cognitive impairment, as indicated by a low score on the Brief Interview for Mental Status. The CNA explained that she stood while assisting the resident in the dining room in case she needed to move and do something else during the meal, although she acknowledged that she was supposed to sit while assisting residents with meals. The Business Office Manager confirmed observing the CNA standing while assisting the resident during both lunch and breakfast. The facility's Administrator stated that staff were expected to sit while assisting residents with meals, as this practice communicated to residents that they and their meals were important and not to be rushed, and that it was a matter of dignity. However, the facility did not have a formal policy requiring staff to sit while assisting with meals, but the expectation was considered part of treating residents with dignity under residents' rights.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly address and resolve concerns raised by the Resident Council, leading to a deficiency in honoring residents' rights to organize and participate in resident/family groups. The Resident Council President reported ongoing issues such as long response times to call lights, staff neglecting to return after promising to assist, and staff refusing to help outside their assigned sections. Additional concerns included late meal deliveries, cold food due to a broken plate warmer, insufficient ice availability, language barriers with staff, and inappropriate staff attendance at council meetings without invitation. Despite these issues being repeatedly raised in meetings from January to July 2024, the facility administration provided no detailed updates or resolutions, leaving residents feeling ignored. The facility's policy on Resident Rights, dated April 1, 2022, mandates that resident groups have the right to meet privately and that the facility must act promptly on grievances and recommendations, providing rationale for their responses. However, the facility's actions did not align with this policy. The Administrator acknowledged the unresolved call light complaints and admitted that the action plan was marked as 'In progress' without actual resolution. The Certified Dietary Manager confirmed ongoing issues with meal delivery and the broken plate warmer, while the Administrator admitted to not paying sufficient attention to the Resident Council's concerns. This lack of effective response and communication contributed to the deficiency.
Failure to Implement Policies and Address Resident Concerns
Penalty
Summary
The facility failed to implement policies effectively, particularly in monitoring previously identified areas of concern and tracking performance to ensure sustained improvements. During the current survey, deficiencies were noted in the facility's handling of Resident Council grievances and recommendations, as well as in the reporting of an abuse allegation. These issues were not addressed adequately, as similar deficiencies were identified in a previous recertification survey conducted earlier in the year. The Plan of Correction (POC) approved by the Quality Assurance and Performance Improvement (QAPI) committee included education for the Interdisciplinary team on the QAPI process and the implementation of plans to prevent repeat deficiencies. However, the survey findings indicated that these measures were not effectively realized or sustained. The Administrator, who took the position in January, expressed surprise at the survey findings, despite having met with the Resident Council and addressing issues observed during his initial weeks in the role.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State agencies as required. The resident, who was readmitted to the facility with diagnoses including encephalopathy, paraplegia, and dementia, was dependent on staff for all activities of daily living and required a Creole interpreter for communication. Her daughter, who was her Power of Attorney, filed a grievance stating that a CNA had verbally abused the resident by yelling and cursing at her in Creole, which left the resident upset and unwilling to eat. The grievance was logged but not reported as an abuse allegation. The Social Services Director, who was responsible for handling grievances, did not consider the incident as abuse because the resident had severely impaired cognition and did not speak. The grievance was mentioned in a daily meeting with the Administrator and other management, but it was not discussed thoroughly. The Administrator, who was the abuse coordinator, was initially confused about the grievance and did not recall being informed about it. He later acknowledged that it could be a verbal abuse allegation that warranted investigation. The facility's policy required abuse allegations to be reported immediately or within 24 hours if no serious bodily injury occurred. However, the grievance was not reported to the State agency, and the investigation was not documented. The Assistant Director of Nursing conducted a quick investigation and concluded that no Creole-speaking staff were assigned to the resident on the dates in question, but no documentation was kept. The facility's failure to report the allegation and properly document the investigation led to the deficiency.
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.
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What surveyors actually found near you
We read the 163 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
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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) |
|---|---|---|---|---|
| Hunters Creek Nursing And Rehab Center | 4.4 mi | ★★★★★ | 1 | 0 |
| Solaris Healthcare Windermere | 5.6 mi | ★★★★★ | 0 | 0 |
| Orlando Health And Rehabilitation Center | 6 mi | ★★★★★ | 3 | 0 |
| South Orange Health And Rehabilitation Center | 6.8 mi | ★★★★★ | 0 | 0 |
| Delaney Park Health And Rehabilitation Center | 7.4 mi | ★★★★★ | 0 | 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.