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 Village On The Green during CMS and state inspections, most recent first.
A resident with a PICC line for IV antibiotics did not have their IV dressing changed as ordered, leading to a deficiency. The facility's policy required dressing changes every two days for gauze dressings, but observations showed the dressing was not changed as documented. The DON confirmed the oversight and inconsistency in documentation.
A resident with multiple health conditions, including acute respiratory failure, was observed receiving oxygen at a flow rate higher than the physician-ordered 2 LPM. Despite the facility's policy requiring staff to review orders before administration, the oxygen concentrator was set at 3 LPM on multiple occasions, as confirmed by the ADON.
A cognitively impaired resident exited a facility unsupervised due to inadequate supervision and a faulty door alarm. The resident, with a history of wandering, was found outside in cold weather. The facility failed to assess the resident's elopement risk accurately and ensure secure exit doors, leading to Immediate Jeopardy.
Failure to Change IV Dressing as Ordered
Penalty
Summary
The facility failed to ensure the proper administration and care of intravenous (IV) therapy for a resident, specifically in changing the IV dressing as ordered. The resident, who was admitted with an infection following a surgical procedure, had a care plan initiated for IV medication use. The care plan included monitoring the IV site for signs of infection and performing peripherally inserted central catheter (PICC) line care as ordered. A physician's order required the IV dressing to be changed weekly, with a specific schedule for changing the injection caps and dressing. However, discrepancies were found in the documentation of dressing changes, with records indicating changes on 3/12/25 and 3/14/25, yet observations on 3/17/25 and 3/18/25 showed the dressing dated 3/12/25 was still in place. The Director of Nursing (DON) confirmed that the dressing, which included a gauze pad under a transparent bandage, should have been changed within 24 hours according to the facility's policy for central venous catheter care. The policy required that sterile gauze dressings, including those under a transparent semi-permeable membrane, be changed at least every two days. The DON acknowledged the oversight and the inconsistency in the documentation, indicating a failure to adhere to the established protocol for IV dressing changes, which could potentially compromise the resident's care.
Failure to Maintain Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to maintain the physician-ordered oxygen flow rate for a resident requiring respiratory care. The resident, who was admitted from the hospital with diagnoses including sepsis, pneumonia, acute respiratory failure with hypoxia, congestive heart failure, type 2 diabetes mellitus, and hypertension, had an active physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the oxygen concentrator was set at 3 LPM, contrary to the physician's order. On one occasion, the resident and his daughter confirmed that they had not adjusted the flow rate, indicating that the incorrect setting was due to staff oversight. The Assistant Director of Nursing (ADON) verified the discrepancy and confirmed the physician's order was for 2 LPM, not 3 LPM. The facility's policy for oxygen administration required staff to review physician orders before administration, which was not adhered to in this instance.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a secure environment, resulting in a cognitively impaired resident exiting the facility unsupervised. The resident, who had severe cognitive impairment and a history of wandering, left the building through an exit door that lacked a delayed egress bar and had an alarm that was not loud enough for staff to hear. The resident was found outside in cold weather, wearing only a gown, approximately 25 minutes after leaving the facility. The resident had been admitted with multiple diagnoses, including dementia, and had a care plan for falls and injuries but not for wandering or elopement risk. The initial elopement evaluation incorrectly assessed the resident as not at risk for elopement, despite the resident's daughter indicating a history of wandering. The facility staff were unaware of the resident's whereabouts until a CNA found her outside and brought her back inside. Interviews with staff revealed that the alarm on the exit door was not loud enough to alert them, and the resident's risk for elopement was not communicated effectively among staff. The facility's failure to assess the resident's elopement risk accurately and ensure the exit doors were secure contributed to the incident, placing the resident and potentially others at risk.
Removal Plan
- Resident #1 was brought back to the room and assessed by Licensed Nurse - no injuries or changes in condition noted. Physician and family were notified by Licensed Nurse and DON.
- DON/Designee completed full head count in Health Center - no other residents were unaccounted for.
- DON/Designee reviewed plan of care interventions, completed Elopement Risk Assessment and implemented interventions for resident now At Risk for Elopement - Electronic wander bracelet order obtained and applied, resident added to Community Elopement Book, resident #1 placed on 1:1 supervision until she was discharged to community.
- All residents' records were reviewed for Risk of Elopement by Administrator and DON - no other residents were identified for risk of elopement. MD notified of the audit - no further orders or modifications to plan of care.
- All exit doors in Health Center were checked by Plant Operations Director for functioning - no Maintenance concerns noted.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was completed with Administrator, Director of Nursing, and Medical Director. A Plan of Correction was initiated.
- Administrator initiated investigation and in-services for nursing staff on resident interventions and elopement prevention policy. Nursing Staff education was completed on for regular staff. Education Topics included Elopement Policy and Procedures, Elopement Assessment and Family Notification.
- An elopement Drill was conducted by Administrator at the Health Center to include Director of Nursing, ADON, Social Service Director, Director of Therapy, RNs, LPNs, CNAs, MDS Coordinator, Admission Assistant, Environmental Service Lead, Therapy Director, Admission Director and Maintenance Lead.
- All doors were noted with a functioning audible alarm.
- Ad Hoc QAPI Meeting was held with Interdisciplinary Team including Administrator, DON, MDS Coordinator, Therapy Director, Lifestyles Director, Maintenance, Social Worker, Medical Records, to review the alleged deficiencies, policy and procedure, and plan of correction.
- Director of Nursing or designee monitor compliance daily and Administrator/DON by checking new admissions records for Elopement Risk and appropriate interventions.
- All new admission records are reviewed daily for Elopement Risk. Any residents noted at risk; interventions are in place.
- Monthly QAPI Meeting was held with Administrator, DON, Medical Director, Social Service Director, MDS, Therapy Director, Registered Dietician, Environmental Services, and Health Information Practitioner and reviewed the alleged deficiencies, policy and procedure, and plan of correction. Audit findings were reviewed at the monthly QAPI Meeting. Reviewed new doors with delayed egress with team.
- In-services were provided by Administrator/Designee all team members on the facility Elopement Policy and Procedures, Elopement Screening Tool and Notification of family. Education will be continued to ensure compliance. Any team member who has not received education will be provided with education prior to reporting to work. All New hires will receive education.
- Monthly QAPI Meeting held Administrator, DON, Medical Director, MDS, Therapy Director, Registered Dietician, ADON, Environmental Services, Lifestyles Director and Health Information Practitioner and reviewed the alleged deficiencies, policy and procedure, and plan of correction. Audit findings were reviewed at the monthly QAPI Meeting. No areas noted out of compliance. Reviewed new doors with delayed egress, plan and specifications for doors have been submitted to county for permitting.
- Elopement Drill with CNAs and Nurses was conducted by the Administrator at the Health Center. Monthly Elopement Drills will be continued to ensure compliance.
- The Administrator/Designee will continue to monitor compliance by completing a random audit of three residents twice per week monthly for the next three months, checking residents medical records for elopement risk and appropriate interventions. Audits were initiated and audits will be continued to ensure compliance.
- The Executive Director provided oversight of the Administrator to ensure that the items on the plan of removal were reviewed and completed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 251 citations issued within 25 miles in the last 12 months — including the 11 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Island Lake Center | 2.6 mi | ★★★★★ | 11 | 0 |
| Harborview Health Center West Altamonte | 2.7 mi | ★★★★★ | 5 | 0 |
| Solaris Healthcare Forest Lake | 3.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Altamonte Springs | 3.7 mi | ★★★★★ | 4 | 0 |
| Longwood Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.