Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rehabilitation Center Of Winter Park during CMS and state inspections, most recent first.
A resident under hospice care experienced a fall, and the LTC facility failed to notify the hospice provider of this change in condition. Despite the facility's policy requiring such notification, the hospice was informed by the resident's wife instead. Interviews with staff confirmed the lapse in communication, and the absence of documentation was validated by the interim DON.
The facility failed to maintain a homelike environment due to unresolved TV issues in multiple rooms, including fuzzy channels, limited availability, and malfunctioning remotes. Despite work orders being marked as completed, problems persisted, causing inconvenience to residents. The Maintenance Director acknowledged the deficiencies, highlighting a lack of effective follow-up and audits.
The facility failed to provide baseline care plan summaries to two residents or their representatives. One resident, admitted with multiple diagnoses including stroke and hemiplegia, had no baseline care plan in their EMR, and no documentation of review or signature. Another resident, admitted with a fall and dementia, also lacked a baseline care plan summary for the current admission, with only a previous admission's plan available. The DON confirmed the absence of proper documentation and was unsure of recent audits or education on care plans.
The facility failed to maintain complete and accurate medical records for two residents. One resident's Admission Agreement was missing, and there were discrepancies in the baseline care plan. Another resident's baseline care plan summary was missing from the electronic record. The DON confirmed the incomplete documentation, which did not adhere to the facility's policies on maintaining accurate records and ensuring residents' rights.
A facility failed to notify a resident's POA of significant changes in the resident's condition and treatment, including a skin tear, bruising, a coughing episode, a medication dosage change, and a rash. Despite the facility's policy requiring notification of the resident's legal representative, there was no documentation that the POA was informed in these instances.
Two residents with severe cognitive impairment experienced multiple injuries of unknown origin, which the facility failed to investigate or report as required by their policy. Despite family concerns and requests, the facility did not document the causes or conduct thorough investigations, nor did they assess other residents for similar injuries.
Two residents with cognitive impairments experienced multiple injuries of unknown origin, which the facility failed to report and investigate in a timely manner. The facility delayed reporting these injuries to the State agency and other entities, exceeding the 24-hour requirement. The facility's abuse policy requires immediate or 24-hour reporting, but this was not adhered to, resulting in a deficiency.
A resident with dementia experienced a delay in treatment due to the facility's failure to timely remove a foley catheter and collect a urine specimen. The catheter was not removed within the physician-ordered timeframe, and the urine sample was collected five days late, delaying the diagnosis and treatment of a urinary tract infection. The DON confirmed the delay in urine collection and catheter removal.
The facility failed to ensure accurate and complete PASARRs for three residents, leading to deficiencies in evaluating their mental health needs. One resident's PASARR did not reflect new diagnoses of anxiety and major depressive disorder, while another's incorrectly indicated no mental illness despite being on medications for delusional and psychotic disorders. A third resident's PASARR lacked updates for new diagnoses post-admission. Delays in correcting these issues were noted due to staff medical leave and ineffective planning.
The facility's QAPI committee failed to sustain prior improvement measures, leading to repeat deficiencies in assessment accuracy and tube feeding standards. Despite monthly meetings to review various areas, the facility was found noncompliant with the same issues cited in a previous survey, indicating insufficient auditing and oversight.
A resident with multiple medical conditions requiring assistance with meals was referred to as a "feeder" by CNAs, which was considered undignified and inappropriate by facility management. The facility's policy emphasizes treating residents with respect and dignity, yet the term persisted, indicating a failure to adhere to these standards.
A resident with mobility issues experienced unsanitary conditions in their room due to a bedside commode not being emptied for two days, resulting in a foul odor. Despite requests, staff failed to address the issue, with CNAs and an LPN involved. The facility's policy and job descriptions emphasize maintaining a clean environment, which was not upheld.
A resident with dysphagia and other conditions was inaccurately assessed in the MDS as needing partial/moderate assistance for eating, despite CNA documentation showing dependency on staff. The MDS Lead confirmed the error, highlighting a failure to ensure accurate assessments.
The facility failed to conduct required PASARR Level I and Level II evaluations for two residents with serious mental health conditions. One resident was admitted with psychosis and major depressive disorder, and another with severe dementia and bipolar disorder, but necessary evaluations were not completed prior to their admissions, as required by facility policy.
A facility failed to create a comprehensive care plan for a resident with diabetes, despite the resident's intact cognition and specific medication orders for diabetes management. The MDS Lead admitted that the care plan was missed due to the resident's frequent hospitalizations, contrary to the facility's policy requiring timely development of care plans based on assessment results.
A resident with severe cognitive impairment and multiple diagnoses was not provided appropriate tube feeding care. The feeding was administered at an incorrect rate and with delays, contrary to physician orders. Staff failed to verify the feeding rate, and the facility's policy on enteral feeding was not followed, as confirmed by the DON and RD.
A resident with end-stage renal disease received Diclofenac gel without proper dosing, as nursing staff failed to follow manufacturer's specifications. The medication was administered unmeasured, contrary to facility policy requiring specific dosage instructions. The DON and Consultant Pharmacist acknowledged the oversight, highlighting a lack of awareness among staff regarding correct dosing procedures.
Two residents were found without access to their call bells, which were out of reach, contrary to the facility's policy. Both residents had significant mobility limitations, requiring assistance for movement and transfers.
A resident with severe cognitive impairment and multiple health issues developed a sacral pressure ulcer, which was not treated promptly due to a delay in implementing the Wound Physician's orders. The facility failed to start the prescribed wound care treatment until three days after the ulcer was identified, resulting in a deficiency in care.
A resident left AMA due to the facility's failure to provide routine medications, while another resident received incorrect medication due to a nurse's error. The facility struggled with timely medication delivery and access to an automated dispensing cabinet, contributing to these deficiencies.
Failure to Notify Hospice Provider of Resident's Fall
Penalty
Summary
The facility failed to notify and update the hospice provider regarding a fall experienced by a resident who was under hospice care. The resident, admitted for respite care, had a medical history including dementia, neurocognitive disorder, depressive disorder, and insomnia. On the date of the incident, the resident was found on the floor next to his bed, and while the facility's Nurse Practitioner was notified, there was no documentation indicating that the hospice provider was informed of this change in condition. Interviews with facility staff, including a Registered Nurse and the interim Director of Nursing, confirmed that the facility's process required notifying the hospice service of any change in condition, such as a fall. However, the hospice provider was not informed by the facility; instead, the resident's wife reported the fall to the hospice service. The interim Director of Nursing validated the absence of documentation in the resident's medical record regarding the notification of the hospice service about the fall, which was a requirement as per the facility's policy.
Deficiencies in TV Functionality and Maintenance Services
Penalty
Summary
The facility failed to provide necessary maintenance services to ensure a comfortable, homelike environment for residents, as evidenced by issues with television functionality in multiple rooms. Residents reported problems such as fuzzy TV channels, limited channel availability, and malfunctioning remote controls. Despite work orders being marked as completed, observations confirmed that the issues persisted, indicating a lack of effective resolution. Residents expressed frustration over the unresolved TV issues, with some reporting that their concerns had been communicated to maintenance staff without satisfactory follow-up. In several instances, remote controls were found to operate multiple TVs in a room, causing inconvenience and disturbance to residents. Additionally, some TVs required frequent reprogramming, and there were instances where residents had to rely on antenna mode to receive clear channels. The Maintenance Director acknowledged the deficiencies, confirming that the TV issues were not homelike and that each resident should have their own functioning remote control. The facility's work order policy and resident rights policy emphasize the importance of maintaining a comfortable environment, yet the lack of audits and effective maintenance follow-up contributed to the ongoing deficiencies in TV functionality.
Failure to Provide Baseline Care Plan Summaries to Residents
Penalty
Summary
The facility failed to ensure that baseline care plan summaries were reviewed with or provided to residents and/or their representatives for two of the four residents reviewed. Resident #1 was admitted with multiple diagnoses, including cerebral infarction and hemiplegia, and resided in the facility for 10 days. Despite the initiation of a care plan upon admission, there was no baseline care plan present in the electronic medical record (EMR) for this resident, and no documentation indicated that the resident or their representative refused to review or sign the baseline care plan summary. The Director of Nursing (DON) confirmed the absence of a baseline care plan in the EMR and provided a paper copy that lacked a date of review or signature from the resident or representative. Resident #2, who was admitted with diagnoses such as a subsequent fall with fracture and dementia, also did not have a baseline care plan summary in their EMR for the current admission. The DON provided a copy of a baseline care plan summary dated from a previous admission, which did not include the signature page for review with the resident or representative. The DON acknowledged that nurses were responsible for the baseline care plans and was unsure if any audits or education had been conducted recently regarding care plans. The facility's policy stated that a written summary must be provided to the resident or representative by the completion of the comprehensive care plan.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For the first resident, admitted with multiple diagnoses including hypertension and diabetes, the Admission Agreement paperwork was missing, and there were discrepancies in the baseline care plan regarding discharge plans and signatures. The Director of Community Relations and the Admissions Director were unable to locate the signed admission agreement, and the Director of Nursing (DON) acknowledged the incomplete baseline care plan. Progress notes also conflicted with the baseline care plan's completion date, indicating a lack of proper documentation and record-keeping. For the second resident, who had a history of falls and other medical conditions, the baseline care plan summary was missing from the electronic record. The DON confirmed the absence of scanned documents for the baseline care plan and provided an incomplete paper copy missing critical information such as the completion date and signatures. The facility's policies emphasize the importance of maintaining accurate records and ensuring residents' rights, yet these were not adhered to, resulting in incomplete documentation for both residents.
Failure to Notify POA of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of changes in condition for one resident reviewed for change in condition. The resident, who had unspecified dementia with unspecified severity, was involved in multiple incidents where the POA was not informed. These incidents included a skin tear on the right forearm, bruises on the forehead and side of the left eye, a coughing episode that required a chest x-ray, a decrease in Trazadone dosage, and a rash treated with Permethrin External Liquid 1%. In each case, there was no documentation that the POA was notified, despite the facility's policy requiring notification of the resident's legal representative or an interested family member when there is a significant change in the resident's status or treatment. The Director of Nursing (DON) and the Assistant Administrator verified the lack of documentation for notifying the POA in each of these instances. The facility's change in condition policy and guidelines for abuse require that the resident's physician and legal representative be notified of significant changes in the resident's condition or treatment. However, the facility did not adhere to these policies, resulting in a deficiency in communication with the resident's POA regarding changes in the resident's health status and treatment.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy and family requests to investigate injuries of unknown origin for two residents. Resident #1, who has unspecified dementia and severe cognitive impairment, experienced multiple injuries, including skin tears and bruises, over several months. The facility did not document the causes of these injuries, nor did they conduct investigations to determine their origins. Despite family concerns and requests for investigation, the facility did not report these injuries to the State Agency or other required entities. Resident #4, also with severe cognitive impairment, was observed with bruising on her hands and forearm. The facility attributed these injuries to blood draws but did not verify the number of attempts or conduct a thorough investigation. Later, the resident's family raised concerns about potential abuse by a CNA, leading to the CNA's suspension. However, the facility did not assess other residents with similar cognitive impairments for unexplained injuries, nor did they report the incident to the State Agency. The facility's policy, dated April 2022, mandates prompt and thorough investigations of abuse and injuries of unknown origin. Despite this, the facility did not follow its guidelines, failing to investigate or report the injuries of the two residents, which could potentially indicate neglect or abuse.
Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin in a timely manner for two residents, leading to a deficiency. Resident #4, who had severe cognitive impairment, was found with multiple bruises on her hands and arms. The facility delayed reporting these injuries to the State agency and other entities, exceeding the 24-hour requirement. The Assistant Administrator confirmed the delay and acknowledged that the facility did not conduct a thorough investigation to determine the cause of the bruises, nor did they notify the appropriate authorities. Resident #1, who had unspecified dementia, experienced multiple injuries, including a skin tear on the right forearm, bruises on the forehead and side of the left eye, and a skin tear on the right elbow and lower leg. The facility did not document the causes of these injuries or conduct investigations to determine their origins. Additionally, the facility failed to report these injuries to the State agency or other required entities, as confirmed by the Administrator and Assistant Administrator. The facility's abuse policy requires that injuries of unknown origin be reported immediately or within 24 hours, depending on the severity. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the injuries sustained by Residents #1 and #4. The facility's failure to follow its own policy and regulatory requirements resulted in a deficiency being identified during the survey.
Delay in Urine Collection and Catheter Removal
Penalty
Summary
The facility failed to timely remove an indwelling urinary catheter and collect a urine specimen for a resident, leading to a delay in treatment. The resident, who had unspecified dementia and was unable to communicate effectively, was initially straight catheterized due to no urine output. A physician ordered a urinalysis with culture and sensitivity and the placement of a foley catheter for three days. However, the catheter was not removed within the specified timeframe, and the urine sample was not collected until five days after the catheter was inserted. The Treatment Administration Record (TAR) lacked instructions for the catheter's removal after three days, and there were missing patency checks on two shifts. Despite documentation indicating the catheter was removed on a specific date, nurses continued to document patency checks afterward. The urinalysis was collected six days after the initial order, and the results were reported two days later, delaying the diagnosis and treatment of a urinary tract infection by nine days. The Director of Nursing acknowledged the delay in urine collection and catheter removal, confirming the delay in treatment.
Deficiencies in PASARR Completion and Accuracy
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) for three residents, leading to deficiencies in the evaluation of their mental health needs. Resident #90 was admitted with diagnoses including bipolar disorder, anxiety, and major depressive disorder, but her PASARR did not reflect the anxiety and major depressive disorder diagnoses. The Social Service Director and the Director of Nursing (DON) acknowledged that a new Level I PASARR should have been submitted following the new diagnoses, but it was not completed. Resident #134 was admitted with multiple diagnoses, including delusional and psychotic disorders, but his PASARR form incorrectly indicated no mental illness. Despite being on medications for these conditions, the PASARR was not updated to reflect his mental health diagnoses. The oversight in updating the PASARR form resulted in a lack of appropriate mental health evaluations and referrals. Resident #22 was admitted with dementia and anxiety, later diagnosed with psychotic disorder and major depression. Her PASARR did not indicate any mental health diagnoses, and no updates were made post-admission. The Social Service Director acknowledged the inaccuracies and initiated an audit to correct PASARRs, but the process was delayed due to her medical leave. The Regional Nurse Consultant noted the delay and the ineffectiveness of the Performance Improvement Plan (PIP) due to a lack of target dates and task delegation.
Repeat Deficiencies in QAPI Committee's Performance Improvement Activities
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility had previously been cited for deficiencies at F641 for the accuracy of assessments and F693 for concerns with tube feeding per physician orders and standards of care during a recertification survey conducted in October 2022. During the current survey, the facility was found to be in noncompliance with the same deficiencies, indicating insufficient auditing and oversight to prevent these repeat citations. The Administrator acknowledged the repeat citations and stated that the process failed, despite the QAPI committee meeting monthly to review various areas, including reportable incidents, clinical metrics, care issues, grievances, and survey activity.
Failure to Maintain Resident Dignity in Meal Assistance
Penalty
Summary
The facility failed to treat a resident requiring assistance with meals in a dignified and respectful manner. The resident, who was readmitted with diagnoses including dysphagia, aphasia, stroke, and contracture of the right hand, was dependent on staff for most activities of daily living, including eating. During interviews, several CNAs referred to the resident as a "feeder," a term deemed inappropriate and undignified by the facility's management. The Keys Unit Manager and the Director of Nursing both stated that residents requiring assistance with meals should be referred to as "dependent diners" instead of "feeders," highlighting the importance of maintaining resident dignity. The Resident Council President also noted that the term "feeder" had been used by CNAs in the past and had been brought to staff attention as demeaning and demoralizing. The facility's policy on Resident Rights emphasizes treating each resident with respect and dignity, and the CNA job description requires care to be provided in a manner that protects and promotes resident rights and dignity. Despite these policies, the use of the term "feeder" persisted, indicating a failure to adhere to the facility's standards for respectful communication and resident dignity.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to provide a sanitary, comfortable, and homelike environment for a resident who was admitted with diagnoses including a left leg above the knee amputation and required assistance with personal care. The resident was observed in his room with a bedside commode that had not been emptied for two days, resulting in a foul odor and the presence of feces and urine. Despite the resident's request to staff during breakfast service to empty the commode, he was informed that it was not their responsibility. Subsequent observations confirmed that the commode remained unemptied, and the odor persisted in the room. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) were involved in the situation. CNA B claimed she was not asked to empty the commode and believed the resident used the bathroom instead. CNA A, who was present the following day, acknowledged the odor but assumed it was due to the resident soiling himself. LPN D was aware of the issue and had instructed CNAs to empty the commode, but it remained unaddressed. The Director of Nursing confirmed that it was the responsibility of any staff to check and empty commodes, and the facility's job description for CNAs included maintaining a clean environment. The facility's policy emphasized providing a safe, clean, and comfortable environment, which was not upheld in this instance.
Inaccurate MDS Assessment for Eating Assistance
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident with significant medical conditions, including dysphagia, aphasia, stroke, and contracture of the right hand. The resident was observed to require extensive assistance for eating, as documented by Certified Nursing Assistants (CNAs) who reported the resident was dependent on staff for eating on multiple occasions. However, the MDS assessments inaccurately recorded the resident as needing only partial/moderate assistance for eating, which was inconsistent with the care plan and CNA documentation. The MDS Lead confirmed that the assessments for March and June 2024 incorrectly showed the resident required partial/moderate assistance, despite evidence indicating the resident was dependent on staff for eating. The MDS Lead acknowledged the importance of accurate MDS assessments for proper resident care and mentioned that any incorrect coding would require revision. The facility's policy emphasized the need for comprehensive and accurate assessments, but the discrepancy in the MDS coding suggests a failure to adhere to these guidelines.
Failure to Conduct Required PASARR Evaluations
Penalty
Summary
The facility failed to request Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluations for two residents, leading to a deficiency. Resident #100 was admitted with diagnoses of psychosis and major depressive disorder, and her medical records indicated severely impaired cognitive skills. A Level I PASARR conducted prior to her admission triggered the need for a Level II evaluation due to a serious mental illness diagnosis. However, the Social Service Director could not locate the Level II PASARR, and it was confirmed that it was not submitted prior to admission, as required. Similarly, Resident #93 was admitted with severe dementia, bipolar disorder, and other mental health conditions. The Social Service Director and the Director of Nursing (DON) were unable to confirm if a Level I PASARR was submitted before his admission, despite the requirement for such a submission. The facility's policy mandates that all residents receive a PASARR in accordance with state and federal regulations, but this was not adhered to in these cases, resulting in a deficiency.
Failure to Develop Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with diabetes, which was identified during a review of the resident's medical records. The resident, who was readmitted to the facility with diagnoses of type 2 diabetes mellitus, lupus, and congestive heart failure, had an intact cognitive status as indicated by a Brief Interview for Mental Status score of 15 out of 15. Despite receiving insulin injections and having specific medication orders for diabetes management, a comprehensive care plan addressing these needs was not developed following the completion of the admission Minimum Data Set (MDS) assessment. The MDS Lead, responsible for overseeing MDS assessments and care plan development, acknowledged that a full care plan should have been completed when the admission MDS assessment was finalized. However, due to the resident's frequent hospitalizations since admission, the care plan was overlooked and not developed until later. The facility's policy stated that assessment results should be used to develop, review, and revise the resident's comprehensive care plan, but this was not adhered to in this case.
Failure to Adhere to Tube Feeding Orders
Penalty
Summary
The facility failed to provide appropriate care for a resident on tube feedings, specifically in relation to the feeding rate and timing. Resident #48, who was severely cognitively impaired and dependent on staff for all care, was readmitted to the facility with multiple diagnoses including metabolic encephalopathy, diabetes mellitus type II, and dysphagia. The resident had an order for Glucerna 1.2 kcal to be administered via PEG tube at a continuous rate of 75 ml/hr for 20 hours, with a scheduled break from 10:00 AM to 2:00 PM. On multiple occasions, the feeding was not administered according to the physician's orders. On one instance, the feeding was stopped later than scheduled due to staff being busy, and the restart was delayed by more than two hours. Additionally, the feeding pump was running at a rate of 60 ml/hr instead of the ordered 75 ml/hr. The LPN responsible for the resident's care acknowledged the discrepancy and admitted to not verifying the rate on the feeding pump, as she was not the original nurse who set it up. The facility's policy required nurses to follow physician orders for enteral feedings, including verifying the rate and documenting any delays. The Director of Nursing confirmed that all nurses received competencies on tube feeding upon hire, and any delays should be documented with the physician notified. The Registered Dietitian highlighted that incorrect feeding rates could lead to unintentional weight loss and poor wound healing, emphasizing the importance of adhering to physician orders.
Improper Administration of Diclofenac Gel
Penalty
Summary
The facility failed to ensure the proper preparation and administration of Diclofenac Sodium External Gel, an over-the-counter medication, for a resident undergoing dialysis. The resident, who had multiple diagnoses including end-stage renal disease and was dependent on renal dialysis, was prescribed Diclofenac gel for pain relief. However, the nursing staff did not follow the manufacturer's specifications for dosing, which required the use of a dosing card to measure the correct amount in grams. Instead, the nurses administered the medication by squeezing an unmeasured amount into a medication cup, unaware of the specific dosing instructions. Interviews with the nursing staff revealed a lack of awareness regarding the need to measure the medication dose accurately. The Director of Nursing acknowledged that the order should have specified a dose, and the Consultant Pharmacist noted that a clarification process should have been initiated to ensure the correct dosage was administered. The facility's policy required medication orders to include specific dosage and frequency, which was not adhered to in this case, potentially putting the resident at risk due to their compromised renal function.
Deficiency in Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call bell system, as observed in the cases of two residents. During an observation, both residents were found in their shared room without access to their call bells, which were attached to the wall behind their beds and out of reach. When asked, one resident indicated that he did not have a call bell, and his roommate confirmed the same. A registered nurse verified the situation and acknowledged that the call bells should have been within reach of the residents. The medical records of the two residents revealed significant mobility limitations. One resident was dependent on staff for movement and required a two-person assist with a mechanical lift for transfers, while the other needed supervision to roll side to side and a minimum assist of one person for transfers. The facility's call bell policy mandates that all residents must have access to call bells at all times, regardless of their ability to use them, and staff are expected to ensure the call bell is within reach while residents are in bed.
Delayed Wound Care for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate care and treatment for a sacral pressure ulcer for a resident, leading to a deficiency in care. The resident, who was readmitted with multiple diagnoses including dysphagia, end-stage renal disease, and severe cognitive impairment, was initially assessed as being at risk for pressure ulcers but did not have any at the time of the assessment. However, a subsequent observation on August 23 revealed an open area on the resident's buttocks, which was later identified as a sacral pressure ulcer by a Wound Physician. The ulcer was described as having necrotic adipose tissue exposed and required specific wound care treatment. Despite the Wound Physician's consultation and orders on August 23, the facility did not commence the prescribed wound treatment until August 27, three days later. The Unit Manager admitted to assuming that the Wound Care Nurse, who had recently resigned, would handle the wound care orders. The delay in treatment was attributed to a lack of communication and documentation, as the Wound Care Physician's orders were not entered or started until days after the consultation. This oversight resulted in the resident not receiving the necessary wound care for several days, which was acknowledged by the Unit Manager.
Medication Administration Failures Lead to Resident Leaving AMA and Medication Error
Penalty
Summary
The facility failed to ensure the availability of routine medications for a newly admitted resident, leading to the resident leaving the facility Against Medical Advice (AMA). The resident, who was cognitively intact, was admitted with multiple diagnoses including cellulitis, acute respiratory failure, and pneumonia. Despite having 12 routine medications ordered, the resident did not receive 8 of these medications during her stay. The facility staff informed her that they were working on obtaining the medications from the pharmacy, but the delay led the resident to bring her own medications from home. When the facility did not allow her to keep her home medications at the bedside, she decided to leave AMA. The facility also failed to administer medications as ordered to another resident, resulting in the resident receiving incorrect medication. This resident, who had mild cognitive impairment, was given Vitamin C instead of the prescribed Vitamin D. The error occurred when a nurse, who was not the resident's usual caregiver, administered the medication. The facility's policy required verification of the right medication before administration, but this protocol was not followed, leading to the medication error. Interviews with facility staff revealed issues with the medication delivery process, including delays in receiving medications from the pharmacy and limited access to the automated medication dispensing cabinet. The Director of Nursing (DON) and other staff members acknowledged the challenges in obtaining medications promptly, especially for newly admitted residents. There was no documentation explaining why the medications were not available, and the facility's process for handling home medications was not effectively communicated to the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 204 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Maitland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens At Depugh | 1.3 mi | — | 0 | 0 |
| Solaris Healthcare College Park | 1.3 mi | ★★★★★ | 0 | 0 |
| Ansley Cove Healthcare And Rehabilitation | 1.4 mi | ★★★★★ | 16 | 3 |
| Parkview Rehabilitation Center At Winter Park | 3 mi | ★★★★★ | 0 | 0 |
| Mayflower Healthcare Center | 3.1 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.