Above 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 South Orange Health And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to properly administer IV antibiotics and maintain a PICC line for a resident with chronic osteomyelitis. The LPN did not use a device to regulate the IV flow rate and altered the infusion rate without physician approval. Additionally, the LPN did not perform required PICC line maintenance tasks, such as changing dressings and measuring arm circumference, and documented these tasks in error.
Two residents did not receive a written summary of their initial care plans due to the facility's failure to hold care plan meetings since November 2024, attributed to staffing shortages. The RN/MDS Coordinator confirmed the absence of documentation for care plan meetings or summaries provided to the residents or their representatives.
The facility failed to administer enteral feeding according to physician's orders for three residents. A resident with severe cognitive impairment did not receive the prescribed nutrition and water, with no documentation to confirm administration. Another resident's feeding was not verified or documented, and a third resident's feeding was set at an incorrect rate. The facility's policy to ensure consistency with practitioner's orders was not followed.
A resident received medications from an LPN who documented under the Unit Manager's name due to not having her own login credentials. The LPN was on her third day of orientation, and the facility lacked policies on precepting and documentation accuracy, leading to improper medication documentation.
A facility failed to administer scheduled medications on time for eight residents, with delays observed on two consecutive days. Nurses were behind schedule due to staffing issues and interruptions, leading to late administration of critical medications for conditions like seizures, mood disorders, and high blood pressure. The DON confirmed the protocol breach and acknowledged the lack of real-time documentation, with no recorded communication to providers about the delays.
A resident's transfer to the hospital was inadequately documented, lacking progress notes, change in condition documentation, and a physician's order. The DON and an LPN were unable to provide details on the transfer, and it was later revealed the resident was sent to the hospital from a physician's office without proper documentation. The facility's policy on accurate and timely documentation was not followed.
A resident with cognitive intactness was found with unauthorized vitamins and a pill in their room, without an assessment for safe self-administration. The facility's policy required an interdisciplinary team assessment and physician's order for self-administration, which was not completed. Staff, including the DON and CNA, were unaware of the resident's possession of these items, indicating a lapse in communication and policy adherence.
A resident with dementia and repeated falls was found on the floor by a CNA, who failed to report the incident immediately and did not follow the facility's fall protocol. The CNA placed the resident back in bed without notifying the nurse, leading to a delay in assessment and treatment. The incident was later classified as neglect after another CNA reported the resident's injuries to the nurse.
A resident with severe cognitive impairment and a history of falls was found on the floor after being left in her room by family. Initial assessments showed no fracture, but later imaging revealed a femoral neck fracture. The facility's investigation was inadequate, lacking camera footage review and comprehensive interviews, and failed to report the incident as required. The facility acknowledged staff should have been aware of the resident's location to ensure safety.
A resident with a history of falls and cognitive impairments experienced multiple falls, including one resulting in a fracture, due to inadequate supervision and failure to implement effective fall prevention measures. Despite being at high risk for falls, the resident was left unsupervised by family members, and staff did not conduct frequent checks as required by the facility's policy.
Failure in IV Antibiotic Administration and PICC Line Maintenance
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics and maintain an IV access site according to professional standards for a resident with chronic osteomyelitis, among other conditions. The resident had a physician's order for Linezolid to be administered intravenously at a specific rate, but during an observation, it was noted that there was no device used to regulate the flow of the IV antibiotic. The assigned LPN admitted to not knowing how to calculate the infusion rate and had altered the rate based on the resident's preference to attend physical therapy, rather than following the physician's order. Additionally, the facility did not adhere to the physician's orders regarding the maintenance of the resident's PICC line. The LPN acknowledged that she had not changed the PICC line dressing or the needleless access device as required and had documented these tasks in error. She also admitted to not measuring the resident's arm circumference or the external portion of the PICC line, tasks that were important to ensure the resident was not experiencing complications from the line. The medication administration records showed blanks indicating that these tasks were not completed on several occasions.
Failure to Provide Initial Care Plan Summaries
Penalty
Summary
The facility failed to provide a written copy or summary of the initial care plan to two residents or their representatives. Resident #2, who was admitted and readmitted with diagnoses including chronic respiratory failure and diabetes, reported not attending a care plan meeting and not receiving a copy of his initial care plan. The RN/MDS Coordinator confirmed that care plan meetings had not been held since November 2024 due to staffing shortages, and no documentation was found to indicate that a care plan summary was provided to the resident or his representative. Similarly, Resident #97, admitted and readmitted with conditions such as encephalopathy and heart failure, did not have a care plan meeting, and her son did not receive a written summary of the initial care plan. The RN/MDS Coordinator acknowledged the absence of care plan meetings since November 2024, and the Administrator explained that the facility's focus was on completing MDS assessments due to reduced staffing. Despite resuming care plan meetings, there was no documentation to show that a summary of the initial care plan was provided to the resident or her representative.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that enteral feeding was administered according to physician's orders for three residents. Resident #84, who had severe cognitive impairment and required tube feeding, did not receive the prescribed amount of Jevity 1.5 nutrition and free water. The feeding pump was not connected, and there was no documentation to confirm that the ordered nutrition and water had been provided. The North Unit Manager and the Regional Nurse were unable to determine how much nutrition and water had been infused, and the resident was overdue for nutrition. Resident #73, also with severe cognitive impairment, had a physician's order for Jevity 1.5 and free water to be administered via feeding tube. However, the nursing staff could not verify or document that the prescribed nutrition and water had been provided. The MAR lacked entries to confirm the administration of the full amount of nutrition ordered by the physician. Resident #42, who was dependent on all activities of daily living and had a feeding tube, was observed with the feeding pump turned off and not connected. Later, the feeding was infusing at an incorrect rate of 56 ml/hr instead of the ordered 95 ml/hr. The nurse confirmed the discrepancy and acknowledged that the feeding should have been set to the correct rate. The facility's policy required that the administration of enteral nutrition be consistent with the practitioner's orders, which was not adhered to in these cases.
Improper Medication Documentation Due to Lack of Login Credentials
Penalty
Summary
The facility failed to accurately document medication administration for a resident, leading to a deficiency in maintaining medical records according to professional standards. A resident, who was admitted with multiple diagnoses including a cervical fracture, hypertension, and diabetes, was observed receiving medications from an LPN who did not have her own login credentials. The LPN administered Potassium Chloride, Hydralazine, and Methocarbamol to the resident, but the administration was documented under the Unit Manager's name due to the LPN's lack of login access. The deficiency occurred because the LPN was still on orientation and had not yet been provided with her own login information. The Unit Manager, who was precepting the LPN, allowed her to document under her name. The Director of Nursing confirmed that the LPN was on her third day of orientation and had not received her login due to a busy schedule. The facility lacked policies on precepting, orientation, or documentation accuracy, contributing to the improper documentation of medication administration.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for eight residents. On two consecutive days, observations revealed that medications scheduled for 9:00 AM were administered late, beyond the one-hour window allowed by the facility's protocol. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B were observed preparing and administering medications well past the scheduled time, with RN A acknowledging being behind due to a staffing shortage and LPN B citing frequent interruptions during medication administration. The Director of Nursing (DON) confirmed that the protocol allowed a one-hour window before and after the scheduled time for medication administration. However, the audit reports showed that medications were consistently administered outside this window. Residents received critical medications for conditions such as muscle spasms, seizures, mood disorders, diabetes, high blood pressure, and heart conditions late. For instance, one resident received their 9:00 AM medications as late as 12:54 PM, and another resident's medications were administered at 10:53 AM, well beyond the acceptable timeframe. The DON acknowledged the late administration of medications and the lack of real-time documentation by some nurses, which was also a violation of professional guidelines. Despite the presence of an Advanced Practice Registered Nurse (APRN) in the facility, there was no documentation of communication regarding the late administration of medications. The facility's policy, which was reviewed and revised in October 2023, mandates that medications be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident who was part of a sample of 13 residents. The resident, a male, was admitted to the facility and later discharged, but there was no progress note, change in condition documentation, physician's order, or transfer documentation available to indicate the resident's condition, reason for discharge, or any care and services provided. An Orders Administration Note mentioned hospitalization but lacked further explanation. The Director of Nursing (DON) confirmed that the required documentation was missing and could not recall the reason for the resident's hospitalization. Licensed Practical Nurse (LPN) C, who was involved in the resident's care, did not recall sending the resident to the hospital or receiving a report about the transfer. The LPN documented the resident's hospitalization in the Medication Administration Record without further details. The DON later learned from the Advanced Practice Registered Nurse (APRN) that the resident was sent to the hospital from a physician's office, but acknowledged that documentation indicating the resident's appointment and subsequent transfer was absent. The facility's policy required accurate and timely documentation of each resident's experiences, which was not adhered to in this case.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for the safe self-administration of medications. Resident #4, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was found to have a pill and several bottles of vitamins on his bedside table. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, there was no documentation or assessment to support that the resident was authorized to self-administer these supplements. During the survey, it was observed that the resident had a pill on his bedside table and four bottles of vitamins, which he claimed to have been taking on his own. The LPN confirmed the presence of these items and stated that the resident was not assessed to self-administer medications. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which had not been completed for this resident. The LPN removed the vitamins and the unidentified pill, citing potential interactions with prescribed medications. The Director of Nursing and other staff members, including a CNA and the North Wing Unit Manager, were unaware of the resident's possession of these vitamins. The facility's policy mandated that any unauthorized medications found at the bedside should be reported and removed, which was not adhered to in this case. The Administrator confirmed that the resident was not supposed to have these items without the facility's knowledge, highlighting a lapse in communication and adherence to the facility's medication management policies.
Neglect in Fall Incident Reporting and Response
Penalty
Summary
The facility failed to provide appropriate care and services following a fall with injury for a resident, leading to a deficiency in protecting residents from neglect. The resident, an elderly female with a history of repeated falls, dementia, and functional quadriplegia, was found on the floor by her assigned CNA. Despite noticing redness on the resident's face, the CNA did not follow the facility's fall protocol, which required immediate reporting and assessment by a nurse. Instead, the CNA picked the resident up and placed her back in bed without notifying the nurse or initiating the fall code procedure. The incident was not reported to the resident's assigned nurse until approximately one hour and forty-five minutes later, when another CNA noticed the bruise on the resident's face and informed the nurse. The nurse then assessed the resident, documented the findings, and sent the resident to the hospital for further evaluation. The delay in reporting and the failure to follow proper procedures were identified as neglect by the facility's investigation. The facility's investigation revealed that the CNA was afraid to report the fall immediately, fearing the nurse's reaction. The CNA was subsequently suspended and terminated, but the facility had not reported the CNA to the Board of Health as of the time of the survey. The facility's fall program required a minimum of a two-person assist or mechanical lift for such incidents, which was not adhered to in this case.
Inadequate Investigation of Resident Fall with Fracture
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall incident involving a resident, which resulted in a fracture. The resident, a female with severe cognitive impairment and a history of falls, was found on the floor in her room after being left there by her family. Initial assessments and X-rays did not reveal any fractures, but subsequent complaints of pain led to further imaging that identified a fracture of the femoral neck. The facility did not complete or submit the required State Agency Nursing Home Federal Report regarding the fall with fracture. The investigation conducted by the facility was inadequate, as it did not include a review of camera footage to verify the timeline of events or a comprehensive interview process. The facility's root cause analysis concluded that the fall was due to the family leaving the resident in her room without staff knowledge. However, the facility acknowledged that staff should have been aware of the resident's whereabouts to ensure her safety. The investigation did not include an interview with the resident due to her cognitive impairment, and the staff involved could not recall specific details about the incident. The facility's policies on fall prevention and abuse, neglect, and exploitation were not fully adhered to, as the investigation lacked thorough documentation and did not involve all potential witnesses. The Administrator admitted that there was room for improvement in the investigation process and acknowledged that staff should have been more vigilant in monitoring the resident's location. The failure to conduct a comprehensive investigation and report the incident appropriately contributed to the deficiency identified by the surveyors.
Inadequate Supervision Leads to Resident Fall and Fracture
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall with a fracture for a resident who was at high risk for falls. The resident, a female with a history of traumatic subdural hemorrhage, cognitive impairments, schizophrenia, and difficulty walking, was admitted to the facility with a history of falls. Her assessments indicated she required substantial assistance for personal hygiene and transfers, and she was identified as being at high risk for falls. Despite these assessments, the resident experienced multiple falls during her stay, including an unwitnessed fall that resulted in a fracture. The incident log revealed that the resident had an unwitnessed fall on one occasion when she was found sitting on the floor, and another fall occurred when she attempted to walk from her bed to her wheelchair. The facility's interventions included placing the bed in a low position and conducting frequent checks, but these measures were insufficient to prevent further falls. The resident's care plan was revised to include educating the family to leave the resident in the common area after visiting and to call staff for assistance with transfers. Interviews with staff indicated that the resident's family often transferred her without staff assistance, despite being informed of the facility's protocols. On the day of the incident, the resident was left in her room by a family member, and staff did not observe her until she was found on the floor. The facility's policy for high-risk residents included increased frequency of rounds and family education, but these protocols were not effectively implemented, leading to the resident's fall and subsequent fracture.
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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) |
|---|---|---|---|---|
| Delaney Park Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Westminster Towers | 0.8 mi | ★★★★★ | 0 | 0 |
| Orlando Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Commons At Orlando Lutheran Towers | 1.3 mi | ★★★★★ | 1 | 0 |
| Guardian Care Nursing & Rehabilitation Center | 2.3 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.