Below 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 Ocoee Transitional Care Center Llc during CMS and state inspections, most recent first.
A resident admitted with UTI, Enterococcus faecalis bacteremia, and presumptive infective endocarditis had hospital and ID orders for IV ampicillin 2 g q4h to continue through a January stop date, but the Admission Nurse entered an incorrect December stop date into the facility’s system, which was then confirmed by an RN. The care plan and MAR reflected this erroneous end date, and IV ampicillin was administered only until mid-month, then stopped, resulting in 59 missed doses before the error was later discovered. A medication occurrence report cited omitted doses due to admission order and chart check errors, and leadership confirmed that staff and pharmacy failed to catch the discrepancy between the electronic order and the written hospital/ID orders.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had hospital infectious disease orders for Ampicillin 2 g IV Q4H through a January stop date. When admission orders were entered into the eMAR (PCC), the admissions nurse transcribed the stop date incorrectly as December instead of January. Although the pharmacy provider received faxed orders with the correct stop date and was contractually responsible for verifying that faxed orders matched PCC entries, its medical records department did not identify the discrepancy. A pharmacist from the pharmacy provider completed a Drug Regimen Review with no recommendations, and a contracted consultant pharmacist performed an admission Medication Regimen Review and documented no irregularities, despite policies requiring thorough review of orders, documentation, and stop dates. As a result, the IV antibiotic was automatically stopped on the incorrect December date, and the resident missed multiple scheduled doses until the error was discovered and the medication was resumed.
A resident admitted with UTI, Enterococcus faecalis bacteremia, sepsis, anemia, and a presumptively infected atrial thrombus had hospital orders for IV ampicillin q4h and ceftriaxone q12h to run concurrently through a specified January stop date. On admission, the ampicillin order was entered into the EHR with an incorrect December stop date, while the ceftriaxone order was entered correctly. The RN Charge Nurse’s verification and a subsequent 24-hour chart check by an LPN did not detect the incorrect ampicillin stop date, and the care plan also reflected the shortened course. As a result, the resident received ampicillin only until the erroneous December stop date and then missed 59 scheduled doses before the error was later discovered, while ceftriaxone continued as ordered.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had an order for IV Ampicillin every 4 hours with a specified stop date. On admission, an RN entered the wrong stop date into the system, and both the confirming RN and an LPN performing the 24-hour chart check failed to detect that the electronic order did not match the written physician order. Although the pharmacy had the correct stop date and continued sending the medication, it accumulated in the med room until another RN noticed the excess supply and discovered that the antibiotic had been stopped early, resulting in 59 missed doses. Despite facility policies requiring prompt QAPI review and process improvement for medication errors, the error was not brought to an ad hoc QAPI meeting or used to initiate a timely PIP, and was instead deferred to a later scheduled QAPI meeting.
Failure to Follow IV Antibiotic Orders Due to Incorrect Stop Date Entry
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for IV antibiotic therapy for one resident admitted with a UTI, urinary retention, Enterococcus faecalis bacteremia, and presumptive infective endocarditis. Hospital discharge documentation and an infectious disease (ID) physician note specified that the resident was to receive ampicillin 2 g IV every 4 hours through a specified January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly directed continuation of IV ampicillin at that dose and frequency until mid-January. On admission, the Admission Nurse entered the ampicillin order into the facility’s computer system with an incorrect stop date in December instead of the January stop date ordered by the ID physician. The electronic order was entered to run from the admission date with an end date in mid-December, and this incorrect order was confirmed by the RN Charge Nurse later that same day. The comprehensive care plan for antibiotic therapy also reflected the incorrect December stop date. As a result, the Medication Administration Record (MAR) shows that the resident received ampicillin IV every four hours only from the evening of admission through mid-December, at which point the medication was stopped per the erroneous end date. Because of the incorrect stop date and failure to reconcile the electronic order with the hospital discharge and ID orders, the resident did not receive ampicillin from mid-December until the medication was later resumed in late December, resulting in 59 missed doses of IV ampicillin. A Medication Occurrence Report documented this as an omitted dosage error caused by an admission order error and chart check error, noting that the infectious disease orders in the chart had the correct January stop date while the electronic order had the wrong December stop date. The DON confirmed that the Admission Nurse, the RN Charge Nurse, and the pharmacy consultant did not identify the discrepancy at the time of admission, and that the resident’s ampicillin was discontinued earlier than ordered, leading to the lapse in therapy.
Failure of Pharmacy Services and Consultant Pharmacist to Detect Incorrect IV Antibiotic Stop Date
Penalty
Summary
The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day. According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC. Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed. Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.
Omission of 59 IV Ampicillin Doses Due to Incorrect Stop Date Entry and Missed Chart Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when 59 ordered doses of IV ampicillin were omitted. The resident was admitted from the hospital with diagnoses including UTI, Enterococcus faecalis bacteremia, sepsis secondary to UTI, anemia, and a presumptively infected left atrial thrombus. Hospital infectious disease documentation and the discharge summary specified that the resident was to receive ampicillin 2 g IV every 4 hours and ceftriaxone (Rocephin) 2 g IV every 12 hours through a specific January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly indicated that both IV antibiotics were to continue concurrently through mid-January. On admission, the Admission Nurse entered the IV antibiotic orders into the facility’s electronic system (PCC). While the ceftriaxone order was entered with the correct stop date, the ampicillin order was entered with an incorrect stop date in December instead of the January date ordered by the infectious disease physician. The RN Charge Nurse confirmed the admission orders in the electronic system against the physical hospital orders but did not identify the discrepancy in the ampicillin stop date. A 24-hour chart check was then completed by an LPN, who also failed to detect that the ampicillin stop date in the computer did not match the physician’s written orders. The comprehensive care plan that was initiated likewise reflected the incorrect, shortened ampicillin date range. As a result of the incorrect stop date and the missed verification opportunities, the resident received IV ampicillin every four hours only from the evening of admission through the early evening of the erroneous December stop date. After that point, the ampicillin was automatically discontinued in the system, and the resident did not receive any further doses until the medication was later restarted. Review of the MAR showed that the resident missed 59 doses of IV ampicillin between the erroneous discontinuation date and the date the order was resumed, while ceftriaxone continued to be administered as ordered. The medication occurrence report identified the error as an omitted dosage caused by an admission order error and chart check error, and the DON confirmed that the facility’s medication verification processes were not followed, resulting in the resident not receiving ampicillin as ordered during that period.
Failure to Identify Significant IV Antibiotic Omission and Initiate Timely QAPI PIP
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and address a significant medication error involving omitted doses of IV antibiotics for Resident #1 and to initiate a Process Improvement Project (PIP) through its QAPI program. Facility policies on adverse consequences and medication errors, administering medications, medication regimen review (MRR), and QAPI require that medication errors, including omissions, be promptly identified, reported, analyzed by the QAPI committee, and used to drive process improvements. Despite these policies, the facility did not recognize and elevate a serious omission of ordered IV Ampicillin as a quality deficiency in a timely manner. Resident #1 was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had an order for Ampicillin IV 2 g every 4 hours with a stop date of 1/13/2026 per infectious disease orders. On admission, the Admissions Nurse entered the stop date incorrectly as 12/13/2025 instead of 1/13/2026. The RN Charge Nurse, responsible for confirming the order, failed to identify that the stop date entered into the computer system did not match the written physician order. LPN A, who performed the 24-hour chart check, also failed to detect the incorrect stop date, even though the procedure required verifying that the written physician’s order matched what was entered into the electronic system. The pharmacy provider entered the correct stop date of 1/13/2026 in its system and continued sending Ampicillin to the facility, resulting in an accumulation of the medication in the medication room. The error was not identified until RN A noticed an abundance of Ampicillin on 12/24/2025 and performed a chart check, revealing that the medication had been stopped 11 days earlier than ordered. This led to 59 missed doses of IV Ampicillin for Resident #1. Interviews with the ADON, Interim Administrator, and DON confirmed that the facility’s medication verification processes were not followed, that the error was considered significant, and that no ad hoc QAPI meeting or PIP had been initiated prior to the next scheduled QAPI meeting, despite the facility’s policies requiring QAPI involvement in reviewing medication errors and implementing process improvements.
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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 Maryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Place At Maryville | 1 mi | ★★★★★ | 27 | 0 |
| Fairpark Health And Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Shannondale Of Maryville Health Care Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Foothills Transitional Care And Rehabilitation | 2.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Blount County | 6.8 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.