Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tuskawilla Nursing And Rehab Center during CMS and state inspections, most recent first.
Failure to process a resident grievance for missing personal property. A resident with intact cognition reported missing blankets, including an electric blanket, and a CPAP machine, but staff did not file a grievance when the issue was first raised. Multiple staff members knew about the complaint, yet the SSD had no grievance on file and the NHA later acknowledged the grievance should have been initiated when the concern was first reported.
IV dressing changes were not completed as ordered for one resident with a central line, and IV dressing change and monitoring orders were not entered for two residents receiving IV therapy. Staff could not confirm when one dressing had last been changed, and the DON confirmed the facility had no TAR or progress note documentation showing the change. For another resident with a midline IV, RNs and the unit manager confirmed the dressing change and monitoring orders were missing from the record, and an RN said the orders were missed by every nurse caring for the resident for nearly eight days.
A resident with encephalopathy, chronic respiratory failure, COPD, and OSA had a CPAP order that was later discontinued, but the TAR still showed CPAP therapy as given on multiple days even when the resident said she had not used the machine and staff noted no device was available. An LPN said she signed the TAR because she believed the CPAP was at the bedside, while the UM and DON acknowledged the medical record was inaccurate and could not explain the inconsistent documentation.
A resident with dementia and cognitive impairments set off a front door alarm and was found outside the facility. Despite the resident's known elopement risk, the facility did not document the incident or complete an incident report. The Administrator treated the event as a drill, leading to inadequate investigation and documentation, contrary to the facility's policies.
Failure to Process Resident Grievance for Missing Personal Property
Penalty
Summary
The facility failed to support a resident’s right to voice a grievance concerning missing personal property. Resident #3 was admitted with diagnoses including encephalopathy, chronic respiratory failure, COPD, and unspecified obstructive sleep apnea. Her Quarterly MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. During interview, she reported missing about three blankets, including an electric blanket, and her CPAP machine, and stated staff were aware of the missing items but she had not received any follow-up about the grievance. She also stated her blankets were labeled with her information. Interviews with facility staff showed the complaint was known to multiple employees, but a grievance was not filed when the issue was first reported. The SSD, who was also the Grievance Officer, stated she was unaware of the missing items and verified there were no grievances on file for the resident regarding missing property. The assigned nurse confirmed the resident had previously told her about the missing blankets and that the NHA was aware and working on it. A CNA said she had been told about the missing blankets and had informed the Laundry Manager. The NHA later acknowledged he first heard about the complaint in resident council and stated a grievance should have been filed at that time. The DON and NHA also acknowledged that many staff members were aware of the complaint and that a grievance should have been filed when they first learned of it. The facility’s grievance policy stated it would support each resident’s right to voice grievances and actively work toward a conclusion while communicating progress in a timely manner.
IV dressing changes not completed or ordered as required
Penalty
Summary
The facility failed to ensure IV dressing changes were completed as ordered for a resident with a central line and failed to obtain IV dressing change orders for two residents receiving IV therapy. For one resident with end stage renal disease, endocarditis, type 2 diabetes, and bacteremia, the record showed an order for weekly transparent dressing changes to the central line in the right chest and daily ceftriaxone through 5/28/26. The resident was cognitively intact and stated he did not remember when the dressing had last been changed. On observation, the dressing date was unclear, and staff could not confirm when it had last been changed. The DON stated IV dressings should be changed weekly or as needed and acknowledged the facility could not provide TAR or progress note documentation showing the dressing had been changed since admission. For a second resident with sepsis, SIRS, CKD stage 3, and anemia, the record showed intermittent IV fluids and midline IV insertions, but there were no orders for dressing changes or IV site monitoring to match the IV insertions. The resident had severe cognitive impairment and was observed with a midline IV in the left upper arm with a clear dressing. RN B confirmed she could not find orders for dressing changes or monitoring in the medical record and that there was no MAR documentation showing the dressing changes had been scheduled or the IV site monitored. The unit manager also confirmed the orders had not been entered and may have been missed. RN C stated she received the physician order to insert the midline IV and knew batch IV orders included dressing changes and monitoring, but she did not add them because she was unsure when the IV team would insert the line. She said she expected another nurse to enter the dressing change and monitoring orders after insertion, but acknowledged the orders were missed by every nurse caring for the resident for almost eight days. The DON confirmed there were no orders for dressing changes or monitoring and stated she expected nurses to follow the process for entering IV orders so all associated orders were included.
Inaccurate CPAP Treatment Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with encephalopathy, chronic respiratory failure, COPD, and obstructive sleep apnea who had a CPAP order. The resident’s quarterly MDS indicated intact cognition and use of a noninvasive mechanical ventilator. The physician order for CPAP at bedtime and as needed was later discontinued, but the treatment record showed CPAP therapy documented as provided on multiple days in April and May even though the resident stated she had not used the CPAP for a while and was unsure why it had been removed or whether she still needed it. Surveyors found inconsistencies between the TAR, progress notes, and staff statements. The progress notes documented that the resident said she no longer had a CPAP machine and that no device was available, while the TAR still showed the treatment as administered on days when the machine was reportedly not present. An LPN acknowledged signing the TAR and said she documented the therapy because she believed the CPAP was at the bedside and had been applied. The UM and DON stated the documentation appeared inaccurate and could not explain why staff were signing off that CPAP therapy had been provided when there were inconsistencies about whether the machine had been returned or was even available. The facility could not provide a policy on documentation or accuracy of medical records.
Failure to Investigate Possible Elopement
Penalty
Summary
The facility failed to thoroughly investigate a possible elopement incident involving a resident with dementia and other cognitive impairments. The resident, who was at risk for elopement, set off the front door alarm and was found outside the facility. Despite the alarm and the resident's known risk, the facility did not document the incident in the medical record or complete an incident report. Additionally, a new elopement risk evaluation was not conducted following the event. Interviews with staff revealed that the alarm was triggered, and the resident was quickly returned to the unit. However, the facility's Administrator did not collect written statements from all involved staff until nearly two weeks later and did not preserve video evidence of the incident. The Administrator considered the event a drill rather than an elopement, which led to a lack of proper documentation and investigation. The facility's policy required an incident report and documentation in the resident's medical record, which were not completed. The Administrator acknowledged that the documentation and investigation could have been better, indicating a failure to adhere to the facility's policies and procedures for resident elopement.
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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 Winter Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Pointe At Ucf | 3.5 mi | ★★★★★ | 4 | 2 |
| Regents Park Of Winter Park | 3.8 mi | ★★★★★ | 8 | 0 |
| Winter Park Care And Rehabilitation | 4.1 mi | ★★★★★ | 0 | 0 |
| Mayflower Healthcare Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Orlando | 4.3 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.