Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Vivo Healthcare West Orange during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive impairment had a physician DNR order and hospital documentation indicating DNR status, and staff confirmed his DNR wishes with his health care proxy at admission. However, the Florida DNRO form in the record was signed only by a physician and lacked the resident/proxy signature, and staff did not document verification calls or complete the form. When the resident was later found unresponsive, an RN confirmed DNR status in the EMR, but EMS deemed the DNRO form invalid due to missing signatures and initiated CPR until the resident was pronounced deceased, resulting in the resident’s DNR wishes not being honored.
A resident with multiple comorbidities and documented DNR status in the EMR was admitted with a Florida DNRO form that was signed only by a hospital physician and lacked the resident’s or proxy’s signature. Facility staff, including the SSD and nursing leadership, recognized prior to the event that the DNRO was incomplete but did not obtain a valid, signed form. When the resident was later found unresponsive, an RN verified the DNR status in the EMR but still called EMS, then provided EMS with a printed copy of the incomplete DNRO on goldenrod paper. EMS determined the DNRO was invalid and initiated CPR per protocol, ultimately pronouncing the resident deceased after unsuccessful resuscitation, resulting in CPR being performed contrary to the resident’s expressed DNR wishes.
Three residents were found to have inaccurate MDS assessments, with two documented as receiving dialysis they never had and one listed as using a mechanical ventilator when only tracheostomy care was provided. The MDS Coordinator confirmed the errors after reviewing medical records and care plans, but could not explain why the assessments were coded incorrectly.
A resident with a history of falls was found to have a cracked and split bedside fall mat that exposed the interior layer, which could not be properly cleaned. Despite staff acknowledging the mat's poor condition and confirming that it had not been replaced or reported for replacement, the damaged mat remained in use.
The facility failed to re-admit two residents after hospitalization, citing behavioral and insurance issues. One resident remained in the hospital for over two months, while the other stayed for two weeks until alternate SNF placement was found. The facility's actions were inconsistent with its policy and federal regulations, causing significant disruption to the residents' care and well-being.
The facility failed to ensure effective communication and oversight of changes to the plan of care, resulting in the administration of an excessive dose of insulin to a resident. This led to the resident becoming unresponsive due to critically low blood glucose levels and requiring transfer to a higher level of care.
The facility failed to maintain a clean and homelike environment for several residents. One resident's room was found in an unacceptable condition upon admission, and multiple residents reported a severe roach problem. The facility's pest sighting log confirmed ongoing issues, and the facility's policy on Resident Rights was not upheld.
A resident with severe pain due to a recent surgical amputation did not receive timely and effective pain management upon admission. Despite having a care plan, the resident received pain medication only once in 16 hours, and there were discrepancies in the documentation and administration of the medication. The facility's policies for pain management and pharmacy services were not followed, leading to unmanaged pain and discomfort for the resident.
A resident with type 2 diabetes was hospitalized after being found unresponsive with a critically low blood glucose level. Despite the hospitalization, the medical record inaccurately documented that the resident's blood glucose levels were checked and medications were administered two days later. The DON confirmed the documentation was inaccurate and against facility policy.
Failure to Ensure Valid DNRO Resulted in Unwanted CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) wishes by not ensuring those wishes were completely and accurately documented to promote continuity of care between providers. The resident, an older male admitted with stroke, type 2 diabetes, essential hypertension, HIV, unspecified dementia, heart failure, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, had a physician order for DNR in the electronic medical record (EMR). His Minimum Data Set assessment showed moderate cognitive impairment, and his care plan included impaired cognitive process with an intervention to communicate with the resident and family regarding his needs. The hospital transfer documentation (3008 form) indicated the resident was DNR, and a Florida Do Not Resuscitate Order (DNRO) form signed by the hospital physician was present in the EMR. On the night of admission, the LPN Supervisor reported that the resident was confused, so she and another nurse contacted the resident’s daughter by phone for consent to treat and to confirm his DNR status. They confirmed with the daughter that the resident’s wish was to be DNR and signed the facility’s Advance Directives Discussion Document, but they did not sign off on the Florida DNRO form. The Social Services Director (SSD) later reviewed the admission packet and noted that the Florida DNRO form was signed only by a physician and lacked any other signature. The SSD stated that she, the former DON, and the former ADON called the resident’s daughter to verify his wish not to have CPR, and confirmed that the two nurses on the call were RNs. However, the SSD could not explain why the nurses did not document this conversation, did not sign the Florida DNRO form until the resident or proxy could sign, and did not obtain the necessary signature by another means. On the morning of the resident’s death, the assigned RN reported that a CNA notified her that the resident was unresponsive at approximately 5:45 AM. The RN assessed the resident, found no blood pressure, pulse, or respirations, and confirmed in the EMR that the resident’s code status was DNR. She then called EMS and, upon their arrival, provided them with a printed copy of the Florida DNRO form, which she located on goldenrod-colored paper in the front office. EMS personnel observed that the form contained only the physician’s signature and lacked the resident’s or authorized representative’s signature, and informed the RN that the form was invalid. EMS then initiated CPR and continued until they discontinued efforts and pronounced the resident deceased. The resident’s daughter later confirmed she was his health care proxy, stated she had informed facility staff at admission that he was DNR, and was later told by facility staff that EMS performed CPR because the Florida DNRO form was not signed. The facility’s own policies required complete, accurate, and timely documentation of residents’ treatment choices and advance directives, but the necessary signatures and documentation for a valid Florida DNRO were not obtained or made available, leading to the failure to honor the resident’s DNR wishes.
Removal Plan
- Notify the attending physician, Medical Director, Administrator, interim DON and resident representative of the incident and initiate an investigation.
- Conduct an immediate 100% audit of all current residents' code status and care plan; verify the presence of a valid Florida DNRO form for each applicable resident in the EMR; confirm the form contains the physician and resident/proxy signatures, signature dates, and legal proxy authority; and contact attending physicians and legally authorized representatives to complete any missing or incomplete Florida DNRO form documentation.
- Print the Florida DNRO form for each applicable resident and place it in Emergency Response Binders.
- Place Emergency Response Binders on each unit, in the rehabilitation (therapy) room, and in social services.
- Initiate advanced directives audits weekly for three months to ensure the Florida DNRO form is complete and valid.
- Implement a revised admission/readmission process that includes Resident Rights and Advance Directive education upon admission, completion of an Advance Directives Discussion Document, and validation of advance directives by Social Services/designee.
- Provide education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Provide education to licensed nurses, the Admissions Coordinator, and the SSD on documentation in the medical record to ensure each resident's medical record contains complete, accurate, and timely documentation.
- Educate the SSD on ensuring accuracy of advance directives and the Florida DNRO form.
- Implement a Florida DNRO form admission and readmission checklist to ensure verification of required signatures, confirmation of proxy authority, proper form completion, and physical availability of the Florida DNRO form.
- Hold an Ad Hoc QAPI committee meeting.
- Complete a 100% chart audit of advanced directives including code status, DNR orders, and Florida DNRO forms.
- Educate all licensed nurses on Resident Rights related to Advanced Directives, verification of advance directives, DNR orders, Florida DNRO forms and requirements, and complete and accurate documentation in the EMR.
- Require completion of a post-test following education to ensure understanding.
- Continue education for new employees.
- Hold Ad Hoc and monthly QAPI meetings with the Administrator, Director of Nursing, Medical Director, and administrative staff.
- Review and revise education, audits, and post-tests as indicated.
- Conduct staff interviews representing all shifts to assess knowledge of advanced directives, verification of code status, completion of the Florida DNRO form, and location of Emergency Response Binders.
Invalid DNRO Led to CPR Against Resident’s Stated DNR Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s Do Not Resuscitate (DNR) wishes were honored due to an invalid Florida Do Not Resuscitate Order (DNRO) form being provided to Emergency Medical Services (EMS). The resident, an elderly male with a history of stroke, type 2 diabetes, heart failure, HIV, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, was admitted with a documented DNR order in the electronic medical record (EMR). A hospital transfer form indicated he was alert but disoriented, required a surrogate for decision making, and was a DNR. The EMR contained a Florida DNRO form dated and signed only by the hospital physician, with no signatures from the resident or an authorized representative, and no power of attorney, health care surrogate, or proxy documents were scanned into the EMR. On the morning of the incident, a CNA found the resident unresponsive at approximately 5:45 AM and notified the assigned RN. The RN assessed the resident, was unable to obtain a blood pressure, pulse, or respirations, and left the room to verify the code status in the EMR, which confirmed the resident was a DNR. Despite this, the RN called EMS and documented that she could not obtain vital signs. She later stated she thought she saw the resident take small breaths and called EMS based on a prior company policy, but could not explain the discrepancy between her observation and her documentation that respirations were absent. When EMS arrived, the RN showed them the DNR order in the EMR, and EMS requested a physical copy of the Florida DNRO form. The RN was unable to locate a paper DNRO form and instead printed the scanned hospital DNRO onto goldenrod paper. EMS determined the form was invalid because it lacked the signature of the resident or his authorized representative and therefore initiated CPR. EMS performed three rounds of CPR before discontinuing efforts and pronouncing the resident deceased at 6:40 AM. Interviews with the resident’s daughter confirmed she was his health care proxy, that she had informed facility staff of his wish to be a DNR, and that she was later told EMS performed CPR because the Florida DNRO form had not been signed. The Social Services Director and facility leadership acknowledged that staff had recognized the hospital DNRO form was incomplete prior to the event but failed to ensure a valid, signed Florida DNRO form was obtained and available, resulting in EMS performing CPR contrary to the resident’s documented DNR status. The facility’s policies for CPR and documentation required adherence to residents’ advance directives and accurate, complete documentation in the medical record. Staff interviews and the facility’s internal investigation confirmed that although the DNR order was present in the EMR and the need for a surrogate and DNR status had been identified, the Florida DNRO form remained incomplete and unsigned by the resident or his proxy at the time of the emergency. During the emergency response, the absence of a valid DNRO form led EMS to determine that CPR must be initiated. This sequence of actions and inactions—failure to complete and validate the DNRO form, lack of proper documentation of the proxy’s authorization on the DNRO, and reliance on an invalid hospital DNRO—resulted in the resident receiving CPR against his stated wishes.
Removal Plan
- Initiated an internal investigation including resident record review and staff interviews; notified the Department of Children and Families, the Florida Agency for Health Care Administration, and local law enforcement; validated notification of the attending physician/medical director and the resident’s responsible party regarding the event.
- Conducted a 100% audit of all current residents’ code status and care plans; verified the presence of a valid Florida DNRO form for each applicable resident in the EMR.
- Conducted code blue drills across all shifts.
- Implemented Emergency Response Binders containing the Florida DNRO form for applicable residents, a facility Florida DNRO verification checklist, and a code status reference guide for staff; placed binders at each nurses’ station, the rehabilitation department, and the social services office.
- Provided education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Educated staff that CPR must be initiated by EMS unless a valid Florida DNRO form is physically available.
- Established designated locations for goldenrod (yellow) paper for Florida DNRO forms to prevent delays.
- Held an Ad Hoc QAPI committee meeting to review education and audits.
- Completed a 100% chart audit of advance directives including code status, DNR orders, and Florida DNRO forms.
- Educated all licensed nurses on Resident Rights regarding Advance Directives; verification of code status and advance directives; DNR orders; Florida DNRO forms and requirements; CPR policy and EMS response requirements; communication of code status; location of goldenrod (yellow) paper for printing Florida DNRO forms; and complete and accurate documentation in the EMR; administered a post-test to ensure understanding.
- Trained all licensed nurses and had them complete post-tests; continued education to include new employees.
- Conducted Code Blue Drills with licensed nurses; scheduled remaining staff to complete a code blue drill upon return from leave.
- Held Ad Hoc QAPI meetings and a Monthly QAPI meeting with Administrator, Director of Nursing, Medical Director, and administrative staff to review and revise education, audits, code blue drills, and post-tests as indicated.
- Conducted staff interviews across all shifts to validate knowledge of advance directives, code status verification, Florida DNRO form completion, and location of Emergency Response Binders; validated education, audits, and code blue drill participation through interviews and review of attendance sheets and post-tests.
Inaccurate MDS Assessments for Special Treatments and Procedures
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of special treatments, procedures, and programs. For one resident with epilepsy and tracheostomy status, the MDS assessment inaccurately indicated that she received dialysis, which she confirmed she had never received. Another resident with a history of a nontraumatic brain bleed and tracheostomy was documented as using an invasive mechanical ventilator, but direct observation and staff verification confirmed that only tracheostomy care was provided, with no ventilator in use. A third resident with bladder inflammation was also incorrectly documented as receiving dialysis, which he denied ever having received. The MDS Coordinator reviewed the medical records and care plans for all three residents and verified that the MDS assessments were coded incorrectly. The Coordinator was unable to explain the reason for the inaccuracies, noting that another MDS staff member, who was responsible for the assessments, was not available to provide clarification. The facility's policy requires that all assessments accurately reflect the resident's status at the time of assessment and that each staff member certifies the accuracy of their portion of the assessment.
Failure to Replace Damaged Bedside Fall Mat
Penalty
Summary
The facility failed to maintain a sanitary environment by not replacing a cracked and split bedside fall mat for a resident with a history of falls, abnormal posture, and lack of coordination. The resident's care plan identified a risk for falls and included the use of fall mats as an intervention. During multiple observations, the fall mat at the resident's bedside was found to be cracked and split along its entire length, exposing the interior layer of the mat. Interviews with facility staff confirmed that the mat was in disrepair and could not be properly cleaned. The Director of Maintenance stated that nursing staff were responsible for replacing damaged fall mats, but no replacement had been obtained from central supply, nor had a service request been entered into the maintenance system. The unit manager acknowledged the mat's poor condition and confirmed it was an older version that had not been replaced.
Failure to Re-Admit Residents After Hospitalization
Penalty
Summary
The facility failed to re-admit two residents who were transferred to a higher level of care for treatment of acute conditions. Resident #3, who had multiple psychiatric and medical diagnoses, was sent to the hospital for altered mental status and verbal aggression. Despite being medically cleared for discharge, the facility refused to re-admit him, citing his aggressive behavior. This resulted in the resident remaining in the hospital for over two months while alternate SNF placement was sought, causing significant disruption to his care and well-being. The facility's staff, including the Social Services Director and the Director of Nursing, provided conflicting statements regarding the decision not to re-admit the resident, and the facility's Outside Marketer/Care Liaison incorrectly stated that the resident was ambulatory and a danger to others, despite documentation showing he was bedbound for years. Resident #2, who had end-stage kidney disease, diabetes, and other complex medical conditions, was transferred to the hospital for acute metabolic encephalopathy due to hypoglycemia. After being medically cleared for discharge, the facility refused to re-admit him, citing insurance issues and the need for the family to complete a Medicaid application. This led to the resident remaining in the hospital for approximately two weeks until another SNF could be found. The facility's Business Office Manager and the VP of Census Development provided inconsistent explanations for the refusal, with the VP of Census Development stating that the facility did not refuse re-admission, despite evidence to the contrary from the hospital's case management notes and the insurance company's records. The facility's policy and procedure for transfer and discharge indicate that residents should be permitted to return to the facility upon discharge from an acute care setting unless specific conditions are met, such as the resident's needs cannot be met, or the resident poses a danger to others. However, in both cases, the facility failed to adhere to its policy, resulting in extended hospital stays and significant disruption to the residents' care and well-being. The facility's actions were inconsistent with the stated policy and federal regulations, leading to actual harm for the residents involved.
Failure to Ensure Effective Communication and Oversight of Insulin Orders
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and oversight of changes to the plan of care by members of the interdisciplinary team (IDT) for a resident. This failure resulted in the administration of an excessive dose of insulin, rendering the resident unresponsive due to a critically low blood glucose level, and necessitating transfer to a higher level of care for treatment. The resident, who had a history of type 2 diabetes with long-term insulin use, end-stage kidney disease with hemodialysis, and other complex medical conditions, was admitted to the facility and had a care plan for diabetes management that included monitoring blood glucose levels and administering insulin as ordered. However, discrepancies in medication orders and lack of proper review led to the administration of both Detemir and Levemir insulin, resulting in a total of 42 units in 24 hours, which was more than double the intended dosage. The medical record review revealed that the resident received a one-time dose of Detemir 22 units and an additional dose of Detemir 20 units on the same day, followed by another dose of Levemir 22 units at bedtime. This excessive insulin administration caused the resident's blood glucose level to drop to 25 mg/dL, leading to unresponsiveness. Despite the nurse's attempts to increase the blood glucose level with Glucagon, the resident remained unresponsive and was eventually transferred to the hospital. The hospital records confirmed the resident's critically low blood glucose level and the diagnosis of acute metabolic encephalopathy due to hypoglycemia. Interviews with the Director of Nursing (DON), the Advanced Practice Registered Nurse (APRN), and the attending physician revealed a lack of awareness and communication regarding the changes in insulin orders. The DON acknowledged that the IDT review process did not involve pulling up residents' charts to identify discrepancies or contraindications in medication orders. The APRN confirmed that she would not have ordered an additional dose of insulin without proper review and clarification. The attending physician expressed concern over the incident and the outcome. The facility's failure to thoroughly review and communicate medication orders led to the administration of an excessive dose of insulin, resulting in actual harm to the resident.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to promote a clean, comfortable, and homelike environment for several residents. Resident #6 was admitted with type 2 diabetes and a skin infection, and her room was found to be in an unacceptable condition. The room had stained sheets, dried urine stains under the toilet seat, and a used plastic container on the toilet lid. Despite the granddaughter's complaints, it took two hours for staff to remove the container, and the granddaughter had to change the sheets herself. The Admissions Concierge and Housekeeper D acknowledged the room should have undergone a deep clean, but it did not meet the required standards. Resident #5, who was cognitively intact and admitted with a right hip fracture and a history of falls, reported a roach problem in her room and the common areas. She had seen roaches during the day and night and even used her trash can to squash one. The facility's pest sighting log confirmed roach issues in multiple rooms and hallways. Resident #5 had to store a can of roach spray in her bedside commode to feel safe. Resident #7, admitted with type 2 diabetes and heart disease, also reported a severe roach problem in her room. During an interview, a large roach was observed running across the room. Resident #7 and her roommate, Resident #9, confirmed that roaches were a persistent issue, with Resident #9 stating she had a roach in her bed the previous night. The facility's policy on Resident Rights emphasized the right to a safe, clean, and comfortable environment, which was not upheld in these cases.
Failure to Ensure Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure timely and effective pain management for a resident who was admitted with severe pain due to a recent surgical amputation and other medical conditions. Despite having a care plan in place that included administering pain medication as ordered and monitoring pain characteristics, the resident did not receive adequate pain relief. The resident's granddaughter reported that the resident was in severe pain upon admission and did not receive the prescribed Tramadol in a timely manner. The granddaughter's account was corroborated by the resident, who confirmed that she experienced severe pain and received pain medication only once in the 16 hours following her admission. The Licensed Practical Nurse (LPN) assigned to the resident during the evening shift confirmed that she did not have access to the medication dispensing machine and relied on another nurse to retrieve the medication. However, there was no documentation to support that the medication was administered as claimed. The Medication Administration Record (MAR) and the medication dispensing machine's transaction records showed discrepancies, indicating that the Tramadol was not removed or administered as reported. The Director of Nursing (DON) and the pharmacy's records further confirmed that there was no transaction for the medication on the night of the resident's admission. The facility's policies for pain management and pharmacy services were not followed, as evidenced by the lack of proper documentation and timely administration of pain medication. The resident's pain levels were inaccurately recorded, and the nursing staff failed to conduct thorough pain assessments and provide consistent pain relief. The DON acknowledged the discrepancies and the absence of documentation, which contributed to the resident's unmanaged pain and discomfort during her initial hours at the facility.
Inaccurate Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure the medical record accurately reflected the status of and services provided for a resident who was hospitalized. The resident, who had type 2 diabetes with long-term insulin use, was found unresponsive with a critically low blood glucose level and was sent to the hospital. Despite the resident being hospitalized, the medical record inaccurately documented that the resident's blood glucose levels were checked and medications were administered two days after the hospitalization. This discrepancy was confirmed by the Director of Nursing (DON) upon review of the medical record. The facility's policy and procedure for documentation in the medical record, revised in November 2023, required that each resident's medical record contain an accurate representation of the actual experiences of the resident through complete, accurate, and timely documentation. The policy explicitly stated that false information should not be documented. However, the assigned nurse documented services and medications for the resident who was not present in the facility, leading to inaccurate medical records. The DON validated this inaccurate documentation and stated that her expectation was for nurses to document the actual care provided and medications administered.
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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 Ocoee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Bennet Center For Rehabilitation & Healing | 0.7 mi | ★★★★★ | 0 | 0 |
| Orlando Health Center For Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Winter Garden Rehabilitation And Nursing Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Health Central Park | 3 mi | ★★★★★ | 0 | 0 |
| Aviata At Colonial Lakes | 4.5 mi | ★★★★★ | 5 | 0 |
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