Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Conway Lakes Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed that expired food was stored in a cooler, the pot/pan sink sanitizing solution was below the required concentration, and wiping cloths used during meal service were not kept in sanitizing solution between uses, leading to failures in food safety and cross-contamination prevention.
The facility did not initiate required PASARR Level II referrals for two residents after new diagnoses of PTSD, bipolar disorder, and major depressive disorder were identified. The DON confirmed that Level II screenings should have been completed following these new diagnoses, but there was no documentation of such referrals.
A resident with severe cognitive impairment and multiple medical conditions was found with pills left unsecured on the bedside table, despite lacking a physician order for self-administration. Facility staff confirmed that medications should not have been left at the bedside under these circumstances.
A resident's urinary catheter bag and tubing were repeatedly observed resting on the floor and clipped to a trash can, contrary to infection control protocols. The DON, also serving as the Infection Prevention Nurse, confirmed these practices were inappropriate and did not meet required standards.
A resident with a history of stroke, speech deficits, and total dependence on staff was unable to speak and only understood Spanish. The care plan and CNA Kardex did not include the resident's language preference or individualized communication strategies, and staff often provided care in English. Family concerns about the resident's inability to understand staff were communicated to leadership, but the care plan was not updated to reflect these needs, despite the facility's assessment recognizing the importance of culturally and linguistically appropriate care.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards, and appropriate oversight was not provided.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards.
The facility did not effectively implement its QAPI and Risk Management Program policies, resulting in repeat deficiencies under F689 and F610 due to insufficient monitoring and oversight of previously identified concerns. Despite audits and support from corporate leadership, there was a lack of sustained tracking and awareness of ongoing issues, including those related to resident transfers.
A resident with a history of quadriplegia, neurogenic bladder, and recurrent UTIs was readmitted after hospitalization for sepsis and a catheter-related UTI, but the facility failed to obtain or reinstate physician orders for routine suprapubic catheter changes and daily flushes. Despite prior monthly catheter changes and clear hospital discharge instructions, staff did not ensure appropriate orders or care were in place, and there was no documentation of necessary catheter care after readmission.
A facility failed to thoroughly investigate an elopement and a fall with major injury involving two residents. A cognitively impaired resident exited the facility unsupervised and was found at a gas station, but the incident was not documented as an elopement. Another resident with severe cognitive impairment experienced multiple falls, one resulting in a major injury, without adequate investigation or intervention. The facility's documentation and response to these incidents were insufficient, placing residents at risk.
A facility failed to prevent a cognitively impaired resident from eloping, leading to her being found outside unsupervised. Despite an alarm sounding, staff did not immediately respond, allowing the resident to cross a busy road. Another resident with a history of falls sustained fractures due to inadequate supervision and intervention. Staff interviews revealed inconsistencies in the facility's response, and the investigation into the elopement was flawed, contributing to the facility's failure to ensure resident safety.
The facility failed to document and report multiple resident elopements, including one where a resident reached a gas station. Staff reported fear of retaliation and were instructed not to document incidents. The DON and NHA denied knowledge of the events until confronted, leading to a new investigation by regional authorities.
A resident with a history of cognitive impairment was inaccurately assessed as having no cognitive deficits upon admission to a facility. This led to the resident not being identified as an elopement risk, resulting in the resident leaving the facility unsupervised. The initial assessment failed to reflect the resident's true mental status, as later evidenced by a BIMS score indicating moderate cognitive impairment.
A LTC facility failed to maintain accurate medical records, leading to deficiencies in documentation and communication. A resident with dementia eloped unnoticed, and staff were instructed not to document the incident. Another resident exhibited exit-seeking behavior, but there was a lack of documentation regarding physician notification and interventions. A third resident experienced multiple falls without proper documentation or new interventions. Additionally, an admission assessment was incomplete, leaving gaps in the care plan. These issues highlight significant lapses in record-keeping and communication.
A resident with multiple health conditions developed a pressure ulcer that was initially misclassified and inadequately documented by the LTC facility. The wound worsened, leading to necrotic tissue and infection, which was not communicated effectively to the wound care provider. The resident was eventually transferred to a hospital with a diagnosis of sepsis and a stage IV sacral wound, resulting in actual harm and the resident's subsequent death.
The facility failed to maintain proper infection control practices, as CNAs were observed using shared vital sign equipment without cleaning it between residents. This occurred on two occasions, where CNAs used incorrect cleaning methods or did not clean the equipment at all, contrary to the facility's infection control policy.
A resident admitted to the facility after ankle surgery did not have physician orders for surgical site care, leading to unmanaged bleeding and hospitalization. Upon readmission, the facility failed to secure necessary follow-up care instructions, resulting in continued neglect of the surgical site. Staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
The facility failed to develop comprehensive person-centered care plans for two residents, one with PTSD and another with dementia, leading to inadequate care planning for their medical, mental, and psychosocial needs. The Social Services Director and Director of Nursing were unaware of critical diagnoses and medications, resulting in a lack of appropriate care plans.
A resident with severe cognitive impairment was found with an undated gauze dressing on her lower left leg, and staff were unaware of any treatment orders or the reason for the dressing. The facility failed to document the treatment and did not obtain a physician's order, which is against their policy.
The facility failed to provide proper IV care for two residents. One resident's PICC line dressing was not changed as required, and another resident's peripheral IV dressing was loose and not changed timely. The nursing staff did not follow protocols, and appropriate physician orders were not entered, leading to lapses in care.
Deficient Food Storage, Sanitation, and Cross-Contamination Prevention
Penalty
Summary
The facility failed to ensure safe food storage, preparation, and sanitation practices in accordance with professional standards. During a kitchen inspection, a container of turkey labeled with a use-by date nearly two months past was found in the reach-in cooler, and the Dietary Manager confirmed it should have been discarded. Additionally, the sanitizing solution in the pot/pan sink was tested and found to be below the required concentration for effective sanitation, with the Dietary Manager acknowledging the deficiency. Further observations revealed improper handling of wiping cloths during meal service. In both the dining room kitchenette and the main kitchen, cooks used wiping cloths to clean plates and then placed the soiled cloths on the counter instead of in a sanitizing solution, as required by facility policy. The Dietary Manager confirmed these practices and stated that the cloths should have been kept in sanitizing solution between uses to prevent cross-contamination.
Failure to Initiate PASARR Level II Referrals After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that appropriate referrals for Preadmission Screening and Resident Review (PASARR) Level II evaluations were made for two residents after new diagnoses of serious mental illness were identified. For one resident, the most recent Level I PASARR assessment did not indicate a diagnosis or suspicion of serious mental illness or intellectual disability, and no Level II evaluation was initiated, despite the resident having a diagnosis of PTSD documented in the facility's records. For another resident, a Level I PASARR was completed prior to the resident receiving new diagnoses of bipolar disorder and major depressive disorder, and there was no evidence that a Level II PASARR evaluation was conducted following these diagnoses. The Director of Nursing confirmed that Level II PASARR screenings should have been completed for both residents after the new diagnoses were made.
Medications Left Unsecured at Bedside for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure that medications were securely stored for a resident with severely impaired cognition. The resident, who had diagnoses including sepsis, bacteremia, urinary tract infection, type II diabetes, and required assistance with personal care, was observed in bed with two pills left on the bedside table. Review of the medical record showed there were no physician orders permitting self-administration of medications for this resident. The resident stated that the nurse had left the pills for him to take. The Unit Manager confirmed that medications should not have been left at the bedside without a self-administration order, verifying that this action was not in accordance with facility policy or professional standards.
Failure to Maintain Infection Control for Urinary Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with a urinary catheter. On multiple occasions, surveyors observed the resident's catheter bag clipped to a trash can at the bedside, with the base of the urine collection bag resting directly on the floor. These observations were made on three separate dates, and photographic evidence was obtained. The Director of Nursing, who also served as the Infection Prevention Nurse, confirmed during an interview that the catheter bag was attached to the trash can and acknowledged that this was not appropriate, verifying that the catheter urine collection bag should not be on the floor to prevent infection. The deficiency involved one resident with a urinary catheter, and the improper placement of the catheter bag and tubing was repeatedly observed over several days, with confirmation from facility leadership that the practice did not meet infection control standards.
Failure to Address Resident's Communication Needs in Care Plan
Penalty
Summary
The facility failed to develop, implement, and revise a person-centered, comprehensive care plan to address the communication needs of a resident who was dependent on staff for all activities of daily living and had significant language and speech barriers. The resident, who had a history of stroke with residual speech and language deficits, impaired mobility, and other chronic conditions, was only able to understand Spanish and could not speak. Despite this, the care plan and CNA Kardex did not reflect the resident's preferred language or provide individualized communication strategies to address the language barrier. Staff interviews revealed that care was often provided in English, and there were no formal assignments of Spanish-speaking staff to assist the resident. A sign in the resident's room indicated her language needs, but this information was not incorporated into her official care plan. Family members expressed concerns to facility leadership about the resident's inability to understand staff, which led to the resident becoming frightened and withdrawn. The facility's own assessment acknowledged the presence of Hispanic residents and the need for culturally and linguistically appropriate care, but this was not translated into practice for this resident. Both the unit manager and MDS coordinator confirmed that the resident's language preference should have been included in the care plan, but it was not, and there was no evidence that this issue was discussed or addressed in care plan meetings.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The lack of proper supervision and the presence of hazards in the area were directly observed by surveyors during their assessment.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Sustain QAPI Monitoring and Oversight for Repeat Deficiencies
Penalty
Summary
The facility failed to ensure effective implementation of its QAPI (Quality Assurance and Performance Improvement) and Risk Management Program policies, specifically in the areas of monitoring previously identified concerns and tracking performance to verify that improvement measures were realized and sustained. Despite having a policy that outlines a proactive approach to continual improvement and the use of data from various sources to identify and address areas needing attention, the facility did not adequately audit or oversee the corrective actions for previously cited deficiencies. Repeat deficiencies under F689 and F610 were identified during the current survey, which had also been cited in a prior complaint survey, indicating that prior corrective actions were not sufficiently monitored or maintained. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that, although audits and environmental modifications were conducted and corporate leadership provided support, there was a lack of awareness regarding ongoing issues, such as those related to residents' transfers. The DON confirmed that regional leadership was involved in reviewing reports before submission to the State Survey Agency, but the NHA acknowledged that the process of addressing these concerns was still ongoing and that further cultural change and improvement in QAPI practices were needed.
Failure to Ensure Appropriate Suprapubic Catheter Care After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to a long-term resident with a suprapubic catheter (SPC) following hospitalization. The resident, who had a history of quadriplegia, traumatic brain injury, neurogenic bladder, and recurrent urinary tract infections (UTIs), was readmitted to the facility after a hospital stay for sepsis and catheter-related UTI. Upon readmission, there were no physician orders in place for changing the suprapubic catheter, despite previous orders for monthly changes and daily flushes, and despite the resident’s complex urological history and recent hospital discharge instructions. Medical record review showed that prior to hospitalization, the resident’s SPC was changed monthly at the facility, and during the hospital stay, the catheter was changed twice. However, after the resident returned to the facility, the previous order for monthly catheter changes was not reinstated, and no new orders were obtained for catheter changes or daily flushes. Interviews with nursing staff and the unit manager revealed that they were aware of the need for regular catheter care but did not ensure that appropriate orders were in place. The resident’s sister reported that she had communicated the hospital discharge instructions regarding daily flushes and monthly changes to facility staff, but these instructions were not documented or acted upon. Further review of the resident’s orders and care plan indicated that only general monitoring and as-needed irrigation were ordered, with no specific instructions for routine catheter changes or daily flushes. Progress notes did not show any evidence of staff contacting the urologist or primary care provider to clarify the care needed for the SPC. The facility’s policy required documentation of all catheter care, but there was no evidence that the necessary care was provided or documented after the resident’s readmission, resulting in a failure to meet the standard of care for residents with indwelling catheters.
Inadequate Investigation of Elopement and Fall Incidents
Penalty
Summary
The facility failed to conduct an accurate and thorough investigation for a potential allegation of neglect related to elopement for one resident and a fall with major injury for another resident. The first incident involved a cognitively impaired female resident who exited the facility through an east wing door without staff knowledge. She traversed a parking lot and crossed a busy road, eventually being found at a gas station by the Night Supervisor. Despite the resident's muddy and wet clothing indicating a fall, the facility did not document the incident as an elopement, nor did they conduct a thorough investigation or implement appropriate interventions to prevent future occurrences. The facility's investigation into the elopement was inadequate, as it failed to accurately document the resident's actions and the staff's response. The Director of Nursing (DON) and Nursing Home Administrator (NHA) initially denied any elopement incidents, and the DON later described the event as a near miss, claiming the resident was supervised the entire time. However, interviews with staff and video evidence contradicted this account, revealing that the resident had indeed left the facility property. The facility's failure to report the incident to the state and to conduct staff education or drills following the elopement further highlights the lack of a comprehensive investigation. In the second incident, a resident with severe cognitive impairment experienced multiple falls, one resulting in a major injury. The facility's documentation and investigation of these falls were insufficient, as there was no evidence of a thorough review by the Interdisciplinary Team (IDT) or the implementation of new fall prevention interventions. The resident's medical record lacked pertinent details about the falls, and the facility's incident logs did not accurately reflect all occurrences. This lack of documentation and follow-up placed the resident at continued risk for falls and injuries.
Failure to Prevent Elopement and Falls in Cognitively Impaired Residents
Penalty
Summary
The facility failed to appropriately evaluate, monitor, and prevent a cognitively impaired resident from exiting the facility unsupervised, leading to an elopement incident. A resident with a history of syncope, orthostatic hypotension, Parkinson's disease, and dementia exited the facility without staff knowledge through an alarmed door. Despite the door alarm sounding, staff did not immediately identify the resident's absence, allowing her to traverse a parking lot and cross a busy road in the dark. She was found approximately 30 minutes later by the Night Supervisor, sitting on the ground in front of a closed gas station, indicating a significant lapse in supervision and response to the alarm. The facility's failure to develop and implement appropriate interventions also resulted in harm to another resident with a history of falls and cognitive impairment. This resident sustained bilateral humerus fractures after a fall, highlighting the lack of adequate supervision and intervention for residents at risk of falls. The resident's medical record indicated a history of falls, yet the facility did not conduct a new fall risk assessment after multiple incidents, nor did they implement effective measures to prevent further falls. Interviews with staff revealed inconsistencies in the facility's response to the elopement incident. The Night Supervisor and other staff members were aware of the resident's elopement, but the Director of Nursing and Nursing Home Administrator initially denied knowledge of the incident. The facility's investigation into the elopement was flawed, as it concluded that the resident did not leave the property, despite evidence to the contrary. This mismanagement and lack of accurate documentation further contributed to the facility's failure to ensure a safe environment for its residents.
Failure to Report and Document Resident Elopements
Penalty
Summary
The facility failed to effectively communicate and implement its compliance and ethics program, leading to multiple incidents of resident elopement that were not properly documented or reported. An anonymous complaint revealed that a male resident had eloped from the facility, and a female resident had previously eloped during the night shift, reaching a gas station down the street. Staff interviews confirmed these incidents, but the facility's reportable and adverse incidents log did not reflect any documented cases of elopement or neglect related to these events. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were unaware of the elopements, despite staff members recalling the events and the Night Supervisor reporting the incidents to them. The Night Supervisor recounted using her personal vehicle to retrieve a resident from a gas station and reported the incident to the NHA and Assistant Director of Nursing (ADON). However, the DON and NHA denied knowledge of the incidents until confronted with staff statements. Staff members expressed fear of retaliation and reported being instructed not to document the incidents or to alter their statements. The facility's administration, including the DON and NHA, were found to have inconsistencies in their accounts of the events, with some staff members alleging that they were told to keep details of the incidents hidden. The Regional President and Director of Corporate Compliance acknowledged trust issues within the facility's administration and initiated a new investigation. The Medical Director was unaware of the incidents and expressed concern over the lack of documentation and reporting, emphasizing the need for ethical handling of such situations.
Inaccurate Assessment Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure an accurate initial comprehensive assessment of a resident's mental status, which contributed to an elopement incident. The resident, admitted for short-term rehabilitation, had a history of syncope, orthostatic hypotension, Parkinson's disease, dementia with agitation, and cognitive communication deficit. Despite hospital records indicating hallucinations, decreased safety awareness, and impulsiveness, the facility's admission assessment inaccurately noted the resident as alert and oriented with no cognitive deficits. Consequently, the resident was not identified as an elopement risk, and appropriate interventions, such as increased supervision or an electronic wander prevention bracelet, were not implemented. The resident's care plan, initiated after admission, acknowledged impaired cognitive function due to dementia, yet the initial assessment failed to reflect this accurately. The resident subsequently exited the facility unsupervised and walked to a nearby gas station. A post-elopement assessment still inaccurately described the resident as alert and oriented. The discrepancy between the resident's documented mental status and the actual cognitive impairment, as evidenced by a BIMS score of 8/15, highlights the facility's failure to conduct a thorough and accurate assessment, leading to inadequate care planning and supervision.
Deficiencies in Documentation and Communication in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation and communication. Resident #3, who had a history of syncope, orthostatic hypotension, Parkinson's disease, and dementia, eloped from the facility unnoticed and was found at a gas station. Despite the incident, there was no documentation in the medical record detailing the elopement, and staff were instructed not to document the event. The Director of Nursing (DON) later entered an Interdisciplinary Team (IDT) note that inaccurately described the incident, and there was no evidence that the physician or family were notified. Resident #1, diagnosed with Alzheimer's disease and Parkinson's disease, exhibited exit-seeking behavior, but there was a lack of documentation regarding the physician's notification and the subsequent order for an electronic wander prevention bracelet. Staff were reportedly instructed not to document an incident where the resident left the facility and was brought back by a parking attendant. This lack of documentation and communication about the resident's behavior and interventions posed a risk to the resident's safety. Resident #5, who had Alzheimer's disease and a history of falls, experienced multiple falls that were not properly documented or addressed with new interventions. There was no evidence of neurological checks after an unwitnessed fall, and the Interdisciplinary Team did not review or implement new fall prevention strategies until after another fall occurred. Additionally, Resident #8's admission assessment was incomplete, leaving gaps in the care plan and CNA Kardex, which are essential for guiding staff in providing appropriate care. These deficiencies highlight significant lapses in record-keeping and communication within the facility.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent infection of a pressure ulcer for a cognitively impaired resident. The resident, who had multiple diagnoses including type II diabetes mellitus, vascular dementia, and Parkinson's disease, was at risk for pressure ulcers but initially had no unhealed pressure ulcers upon admission. However, a new pressure ulcer was identified on the resident's coccyx, which was initially classified as Moisture Associated Skin Damage (MASD) and later reclassified as an unstageable pressure wound with necrotic tissue and purulent drainage. The facility's documentation and communication regarding the resident's wound care were inconsistent and inadequate. There was a lack of documentation on daily wound care and changes in the wound's condition, despite the presence of necrotic tissue and purulent drainage. The wound care provider noted significant changes in the wound's condition, including necrotic tissue and infection, but there was no evidence that the facility staff communicated these changes to the wound care provider in a timely manner. The facility's Director of Nursing acknowledged the absence of documentation and communication regarding the wound's progression. The resident's condition deteriorated, leading to a transfer to a hospital where the resident was diagnosed with sepsis and a stage IV sacral wound. The hospital's examination revealed a sacral wound with exposure of the coccyx bone and surrounding skin necrosis. The facility's failure to provide timely and adequate care and treatments for the pressure injury and infection resulted in actual harm to the resident, who was subsequently placed on hospice care and passed away shortly after.
Inadequate Infection Control Practices with Shared Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices during the use of shared vital sign equipment, leading to the potential spread of dangerous bacteria between residents. On two separate occasions, Certified Nursing Assistants (CNAs) were observed using a portable vital signs monitor to measure blood pressure without cleaning the equipment between residents. In one instance, CNA K measured the blood pressure of a resident with dementia and then proceeded to measure another resident's blood pressure without disinfecting the equipment. The Unit Manager confirmed that CNAs were supposed to clean the equipment between each resident using Caviwipes, as per the facility's infection control manual. In another instance, CNA I was observed using a vital signs machine to obtain readings for multiple residents without cleaning the equipment between uses. The CNA incorrectly used Premium Adult Washcloths instead of the required Sani-cloth wipes for disinfection. The Assistant Director of Nursing (ADON)/Infection Preventionist clarified that Sani-cloth wipes should be used to clean the equipment between residents and that a label should be placed on the equipment once it is disinfected. The facility's policy on standard precautions mandates that reusable equipment must be cleaned and disinfected appropriately before being used for another resident.
Failure to Obtain Admission Orders for Surgical Site Care
Penalty
Summary
The facility failed to obtain admission physician orders for the immediate care of a surgical site for a resident who had undergone an open reduction and internal fixation (ORIF) of the right ankle. Upon admission, there were no orders for the care of the surgical site or for a follow-up visit with an orthopedic physician. The resident presented with significant serosanguinous drainage from the surgical site shortly after admission, and the on-call surgeon was contacted. However, no immediate orders were obtained for the care of the surgical site. The resident was hospitalized shortly after admission due to a critical lab result indicating low hemoglobin and ongoing bleeding from the surgical site. Hospital records indicated that a staple was placed to control the bleeding, and the resident was readmitted to the facility without clear instructions for the care of the surgical site or the removal of the staple. The resident reported that since readmission, no care had been provided for the surgical site, and he had not seen the surgeon. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's surgical site care. The RN/UM and RNC acknowledged the absence of orders for continuity of care and the expectation that such orders should have been obtained. The facility's admission process did not ensure that necessary orders were in place, and there was no policy specifically addressing admission orders, leading to a gap in care for the resident's surgical site.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to meet the medical, nursing, mental, and psychosocial needs of two residents. Resident #33, who was admitted with diagnoses including dementia, depression, and PTSD, did not have a care plan addressing trauma-informed care related to his PTSD. Despite the presence of progress notes indicating symptoms of depression, anxiety, hallucinations, and mild paranoia, the Social Services Director (SSD) was unaware of the PTSD diagnosis and had not read the psychological services notes. This oversight led to the absence of a care plan for trauma-informed care, which was confirmed by both the SSD and the Director of Nursing (DON). The resident's daughter reported finding her father crying, highlighting the emotional distress he was experiencing without appropriate care planning in place. Resident #99, admitted with diagnoses including dementia, chronic kidney disease, and chronic obstructive pulmonary disease, also lacked a comprehensive care plan addressing his cognitive impairment, dementia care, or behaviors. The resident was prescribed antipsychotic, antianxiety, and antidepressant medications, but the SSD was unaware of these prescriptions and the behaviors that warranted them. The DON confirmed the absence of a care plan for cognition and dementia care and could not locate documentation regarding the resident's behaviors prior to medication prescription. This lack of coordination and documentation resulted in inadequate care planning for the resident's needs.
Failure to Document and Obtain Physician Order for Wound Treatment
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with professional standards of practice regarding non-pressure related skin wounds. Specifically, the facility treated a wound without a physician order and did not document the treatment for a resident with severe cognitive impairment. The resident was observed multiple times with an undated gauze dressing on her lower left leg, and staff were unaware of the reason for the dressing or any treatment orders related to it. The Director of Nursing (DON) confirmed that there was no documentation or physician order for the dressing, which is against the facility's policy and procedure. The resident, who had a history of Rhabdomyolysis, Major Depressive Disorder, venous insufficiency, Type 2 Diabetes Mellitus, and Bipolar Disorder, was admitted to the facility and later hospitalized due to an unwitnessed fall. Upon return, the resident was found to have a scab on her left lower leg, which started bleeding when the dressing was removed. The DON and LPN involved could not explain how the resident sustained the scab or who applied the dressing. The facility's policy requires nurses to obtain a physician's order for wound dressings and document any treatment, which was not followed in this case.
Failure to Provide Proper IV Care
Penalty
Summary
The facility failed to provide intravenous (IV) care and services according to standards of practice for two residents. Resident #321 was admitted with a peripherally inserted central catheter (PICC) line and had physician orders for IV antibiotics and PICC line care, including weekly dressing changes. However, the dressing on the PICC line, dated 5/2/24, was not changed by the nursing staff until observed on 5/13/24, despite the standard practice of changing it every 7 days. The Licensed Practical Nurse (LPN) responsible for the resident's care admitted to not checking the dressing date, and the Director of Nursing (DON) confirmed that the appropriate batch orders for PICC line care were not entered upon admission, leading to the oversight. Resident #182 had a peripheral IV line inserted with a dressing dated 5/8/24. The dressing was observed to be loose and not secure on 5/14/24. The LPN responsible for the resident's care acknowledged that the dressing should be changed every 3 days or sooner if compromised. However, there were no physician orders to monitor or change the IV dressing, and the DON confirmed that batch orders for IV fluid care, including dressing changes, were not entered by the nurse who obtained the IV order. This resulted in the dressing not being changed as required by the facility's policy. Both cases highlight a failure in the facility's process for ensuring proper IV care and adherence to standards of practice. The nursing staff did not follow protocols for monitoring and changing IV dressings, and there was a lack of appropriate physician orders and documentation. The DON acknowledged these deficiencies and confirmed that the facility's policies were not followed, leading to the observed lapses in care for the residents involved.
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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) |
|---|---|---|---|---|
| Lotus Nursing And Rehabilitation Center | 2.9 mi | — | 0 | 0 |
| Westminster Baldwin Park | 2.9 mi | — | 8 | 0 |
| Solaris Healthcare East Orlando | 2.9 mi | — | 0 | 0 |
| Delaney Park Health And Rehabilitation Center | 3.3 mi | — | 0 | 0 |
| Commons At Orlando Lutheran Towers | 3.3 mi | — | 1 | 0 |
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