Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solaris Healthcare Waterman during CMS and state inspections, most recent first.
Surveyors found that a Wound Care Nurse did not follow infection prevention and control practices for two residents during wound care. For residents with multiple wounds and complex medical conditions, the nurse removed soiled dressings and gloves but failed to perform hand hygiene before donning clean gloves and applying new treatments and dressings. In interviews, the nurse acknowledged that hand hygiene should have been performed with each glove change, and the DON confirmed that the facility’s expectation is for staff to perform hand hygiene when changing gloves during wound care, particularly after cleaning wounds and before applying treatments or clean dressings.
A resident's preference for scheduled showers was not honored when a CNA, due to staffing shortages and delays, did not provide the requested shower or a bed bath, and failed to document or communicate the refusal to the RN. The resident, dependent on staff for bathing, did not receive care as outlined in her care plan, and facility policy regarding ADL support and documentation was not followed.
Three residents did not receive respiratory care consistent with physician orders and professional standards, including incorrect oxygen flow rates and improper storage of nebulizer masks. Staff and DON interviews confirmed expectations for correct oxygen settings and equipment storage, but these were not met.
A resident with a history of C. diff and new onset diarrhea was not placed on contact precautions during testing for possible recurrent infection. Staff, including a CNA and an LPN, entered and exited the resident's room using only hand sanitizer, without donning PPE or following hand hygiene protocols specific to C. diff. Facility policy required contact precautions and hand washing with soap and water, but these were not implemented.
The facility failed to use appropriate isolation signage and ensure proper PPE usage, leading to potential infection risks. Two residents with COVID-19 had incorrect signage, and staff did not wear gowns while providing care to residents requiring enhanced barrier precautions. The Infection Preventionist and DON confirmed these lapses, indicating non-compliance with facility policies.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving oxygen therapy was not correctly documented in the MDS, and another resident's discharge status was inaccurately recorded. Discrepancies in documentation practices were noted.
A resident received Midodrine HCl Oral Tablet 5 MG multiple times despite having a systolic blood pressure greater than the prescribed threshold of 130, contrary to the physician's orders. The Director of Nursing acknowledged the medication error, and interviews with physicians revealed differing views on the impact of the error, with no adverse effects reported.
A resident with documented allergies to peanuts and tomatoes was served a meal with a tomato garnish, despite the facility's system to check meals for allergens. The resident reported limited food options and was at risk due to the oversight.
The facility failed to ensure a resident received the appropriate enteral feed as per the physician's order. The resident's enteral feed pump was observed running at 70 ml/hr instead of the ordered 80 ml/hr. Staff acknowledged the discrepancy, and the Director of Nursing confirmed the expectation to verify and set the correct rate.
The facility failed to store foods and beverages safely and sanitarily in one nourishment room. Surveyors found multiple unlabeled, undated, and expired food items in the refrigerator. The Certified Dietary Manager acknowledged the issue, noting that all items should be labeled with the resident's room number and dates, as per facility policy.
The facility failed to ensure complete and accurate records for a resident receiving oxygen therapy. Observations showed the resident receiving oxygen at 2 liters per minute, but the physician order lacked the specified rate and device. The DON confirmed the order should have included these details, violating the facility's documentation policy.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices, specifically hand hygiene during wound care, for two residents with multiple wounds. For one resident admitted with diagnoses including rhabdomyolysis and methicillin-resistant Staphylococcus aureus (MRSA) infection, physician orders directed daily and as-needed wound care to a left lateral calf wound and treatment of a reddened left hip area. During an observation, the Wound Care Nurse performed wound care on three separate wounds for this resident but did not perform hand hygiene after removing each soiled dressing and her soiled gloves. Instead, she donned clean gloves without hand hygiene and proceeded to administer treatments and apply new dressings. For another resident admitted with conditions including a left femur fracture, severe protein-calorie malnutrition, anemia, hemiplegia and hemiparesis following cerebral infarction, and muscle weakness, physician orders required specific wound care to a skin tear, a coccyx wound, and a left heel area. During an observation, the Wound Care Nurse performed wound care on two separate wounds for this resident and again failed to perform hand hygiene after removing each soiled dressing and her soiled gloves, immediately donning clean gloves and continuing with treatment and dressing application. In interviews, the Wound Care Nurse acknowledged she should have performed hand hygiene each time she removed gloves, and the DON stated the expectation was that nurses perform hand hygiene when changing gloves during wound care, especially after cleaning a wound and before applying treatment or a clean dressing.
Failure to Honor Resident's Shower Preferences and Inadequate Documentation
Penalty
Summary
The facility failed to honor a resident's preference for shower date and time, as required by their care plan and facility policy. On the resident's scheduled shower day, she requested a shower but was told by the CNA that only a bed bath could be provided. The resident declined the bed bath, expressing her preference for a shower, but ultimately did not receive either a shower or a bed bath that day. The CNA later stated that due to being short-staffed, she was delayed in reaching the resident, who then requested only peri-area care and to be put to bed. The CNA did not document the refusal of the bed bath, nor did she inform the RN on duty of the resident's refusal, as required by facility protocol. Review of the resident's records confirmed her dependence on staff for bathing and her specific preference for shower days and times. The care plan emphasized the need for staff to be aware of and incorporate resident preferences into daily care. The facility's policy required that appropriate ADL care be provided in accordance with the resident's plan of care and preferences. However, the lack of communication and documentation by staff resulted in the resident's preferences not being honored and the required care not being provided or properly recorded.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents receiving oxygen therapy. One resident was observed receiving oxygen at 3.5 liters per minute (LPM) via nasal cannula, despite a physician's order specifying 2 LPM. The resident reported not adjusting the oxygen settings themselves. Another resident was observed with a nebulizer mask left unbagged on the bedside table and was receiving oxygen at 4–4.5 LPM, while the physician's order called for continuous oxygen at 5 LPM via nasal cannula. This resident also had orders for scheduled nebulizer treatments. The resident stated that only nurses handled the oxygen equipment. A third resident was observed with a nebulizer mask left unbagged on the bedside table, contrary to facility expectations that such equipment be stored in a plastic bag with a date. Staff interviews confirmed that the nebulizer mask should have been properly stored when not in use. Physician orders for this resident included as-needed nebulizer treatments for shortness of breath or wheezing. The DON confirmed the expectation for correct oxygen settings and proper storage of respiratory equipment.
Failure to Implement Contact Precautions and Proper Hand Hygiene for Suspected C. diff Infection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with a history of Clostridium difficile (C. diff) who was experiencing new onset of diarrhea and was being tested for possible recurrent C. diff infection. Despite physician orders to rule out recurrent C. diff and the resident's report of loose stools, the resident was not placed on contact precautions, and there was no isolation signage or personal protective equipment (PPE) available at the room. Multiple observations over several days showed that staff, including a CNA and an LPN, entered and exited the resident's room using only hand sanitizer, without donning appropriate PPE or following hand hygiene protocols specific to C. diff, such as washing hands with soap and water. Interviews with staff revealed a lack of awareness regarding the resident's C. diff status and the required precautions. The CNA stated they were unaware of the need for contact precautions and relied on signage to identify such cases, while the RN acknowledged that the resident should have been placed on isolation when the order was received. The Director of Nursing also confirmed that precautions should have been implemented immediately. Review of the facility's policy indicated that residents with suspected or confirmed C. diff should be placed on contact precautions and that hand washing with soap and water is required, but these procedures were not followed.
Failure to Implement Proper Isolation Precautions and PPE Usage
Penalty
Summary
The facility failed to utilize appropriate isolation precaution signage and ensure the use of proper PPE, leading to potential transmission of communicable diseases and infections. Resident #19 and Resident #82, both diagnosed with COVID-19, had signs on their doors indicating Enhanced Barrier Precautions instead of the required Droplet Isolation Precautions. This discrepancy was confirmed by the Infection Preventionist. Additionally, Resident #418, who required Enhanced Barrier Precautions for a PICC line, was observed receiving IV medication from an LPN who did not wear a gown. The LPN stated that gloves were sufficient for the task, despite the facility's policy requiring gowns for such procedures. Resident #85, with a history of MRSA and a surgical wound, also lacked appropriate signage and PPE usage, as observed when an Occupational Therapist provided direct care without a gown. The facility's policies on isolation notices and enhanced barrier precautions were not adhered to, as evidenced by the incorrect signage and improper PPE usage. The Director of Nursing and the Infection Preventionist acknowledged these lapses, noting that staff should be fully aware of and compliant with the required precautions. The Infection Preventionist admitted that the signage for Resident #85 was not updated after COVID-19 precautions were lifted, leading to a failure in maintaining enhanced barrier precautions. These deficiencies highlight significant gaps in the facility's infection prevention and control program, potentially compromising resident safety.
Inaccurate MDS Assessments for Oxygen Therapy and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for two residents. Resident #420 was observed receiving oxygen therapy at 2 liters per minute via nasal cannula, as per the physician's order dated 4/5/2024. However, the 5-Day MDS for Resident #420 did not indicate the use of oxygen therapy. The MDS Director admitted to not reviewing the vitals documented by CNAs, relying instead on nurse documentation, which led to the oversight. The Director of Nursing stated that CNA documentation should be considered accurate, highlighting a discrepancy in the documentation process. Resident #115's Discharge MDS inaccurately recorded the discharge status as being to a short-term general hospital, while progress notes indicated the resident was discharged home. The Regional Director of Clinical Reimbursement and MDS Director confirmed the coding error. The facility's policy on Resident Assessment Instrument, last reviewed on 1/16/2024, mandates that the Assessment Coordinator ensures timely and accurate resident assessments, which was not adhered to in these cases.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident received medication as per the physician's order. Specifically, Resident #106 was prescribed Midodrine HCl Oral Tablet 5 MG to be administered every 8 hours for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 130. However, the resident received the medication multiple times when their SBP was above 130, including instances on 4/1/2024, 4/4/2024, 4/8/2024, 4/13/2024, 4/14/2024, and 4/22/2024. These administrations were documented in the Medication Administration Record for April 2024, showing blood pressure readings significantly higher than the prescribed threshold for holding the medication. The Director of Nursing acknowledged the medication error and stated that the physician and resident were informed, with no adverse effects reported by the resident or noted by the physician. However, the facility's policy on medication administration was not followed, leading to this deficiency. Interviews with the Director of Nursing and two physicians revealed differing perspectives on the impact of the medication error. The Director of Nursing admitted the error and mentioned that the physician advised continuing the medication. Physician #1 did not comment on potential side effects, while Physician #2, a cardiologist, downplayed the significance of the error, stating that the dose of Midodrine was very low and unlikely to cause major issues. Despite these reassurances, the facility's failure to adhere to the prescribed medication administration protocol constitutes a deficiency in providing appropriate treatment and care according to the physician's orders and the resident's needs.
Failure to Prevent Serving Allergen Food Items
Penalty
Summary
The facility failed to ensure that a resident was not served known allergen food items. Resident #419, who had been in the facility for a few days, reported that the food options were limited and included items she was allergic to, such as peanut butter sandwiches. During an observation, Resident #419 was served a ham sandwich with a tomato garnish, despite having a documented allergy to tomatoes. The resident stated that if the tomato had been on the sandwich, she would not have been able to eat it due to her allergy. The resident's admission record and hospital records both documented her allergies to peanuts, tomatoes, and other substances. The facility's meal ticket for the resident also listed these allergies. Despite having a system in place to check meals for allergens, the facility failed to prevent the resident from being served a meal with a known allergen. Interviews with staff revealed that the meals are supposed to be checked multiple times, but this process was not effectively followed in this instance.
Failure to Administer Enteral Feed as Ordered
Penalty
Summary
The facility failed to ensure that Resident #170 received the appropriate enteral feed as per the physician's order. Resident #170, who was admitted with diagnoses including hemiplegia, hemiparesis, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, dementia, and gastrostomy status, was observed on 4/23/2024 with an enteral feed pump running at 70 ml/hr. This was contrary to the physician's order dated 4/18/2024, which specified an enteral feed rate of 80 ml/hr for 20 hours daily, with the pump off at 10 am and on at 2 pm, totaling 1600 ml per day. The care plan dated 4/17/2024 also indicated that the resident required enteral tube feeding as ordered. During an interview, Staff E, an LPN, acknowledged the discrepancy and stated that the pump rate needed to be changed to match the physician's order. The Director of Nursing later confirmed that the expectation for nurses was to verify the order and set the pump to the correct administration rate. The facility's policy on enteral tube feeding, last reviewed on 1/16/2024, also emphasized the importance of verifying the physician's order and checking the rate of administration before initiating the feed.
Failure to Store Foods and Beverages Safely and Sanitarily
Penalty
Summary
The facility failed to ensure foods and beverages were stored in a safe and sanitary manner in one of the nourishment rooms. During an observation, surveyors found an unlabeled and undated plastic grocery bag with two containers of unidentifiable food, an unlabeled Taco Bell bag containing one taco, an unlabeled Burger King bag containing a cheeseburger and French fries, and an unlabeled and undated Wendy's bag containing a burger and side salad in the refrigerator. Additionally, four pieces of celery wrapped in saran wrap with a date were found in the butter tray. The Certified Dietary Manager acknowledged the expired and/or undated and unlabeled foods and stated that everything should be labeled with the resident's room number and dates. The facility's policy requires perishable foods to be labeled with the resident's name and dated, and nursing staff is responsible for discarding perishable foods within three days or before the expiration date.
Incomplete Oxygen Therapy Documentation
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for a resident receiving oxygen therapy. During observations on two separate occasions, the resident was seen receiving oxygen via nasal cannula at 2 liters per minute. However, a review of the resident's physician order revealed it was incomplete, lacking the specified rate and device for oxygen administration. The Director of Nursing confirmed that the order should have included these details. The facility's policy requires all services provided to the resident to be documented in the medical record, but this was not adhered to in this case.
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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 Tavares
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ruleme Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Lake Eustis Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 10 | 2 |
| Bayview Center | 2.3 mi | ★★★★★ | 7 | 0 |
| Avante At Mt Dora, Inc | 2.3 mi | ★★★★★ | 11 | 0 |
| Edgewater At Waterman Village | 3.9 mi | ★★★★★ | 9 | 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.