Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lotus Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to promote dignity for two residents requiring mealtime assistance by providing feeding support while standing instead of sitting at eye level, despite available chairs, and by referring to residents as "feeders" rather than using respectful terminology. The facility lacked a formal policy or competency on mealtime assistance, and staff practices did not align with the facility's Resident Rights policy emphasizing dignity and respect.
A resident with multiple medical conditions and cognitive intactness submitted two grievances about a CNA's demeanor and call light response. While the first grievance was addressed and communicated, the second grievance lacked documentation of the outcome and resident satisfaction, despite corrective action being taken. The facility did not follow its grievance policy requiring timely response and documentation.
A resident with chronic heart failure was observed receiving oxygen at 4.5 LPM, contrary to the physician's order of 2 LPM. The LPN and Unit Manager confirmed the discrepancy, highlighting a failure to adhere to the facility's policy on oxygen administration, which requires checking the flow rate every shift.
The facility failed to implement timely QAPI plans, leading to repeated deficiencies in PASARR accuracy and wound care practices. The Administrator, new since April 2024, was unaware of past issues due to ownership changes, and no Performance Improvement Plans were in place for these concerns.
The facility failed to update Level I PASARRs for three residents, resulting in inaccurate records that did not reflect their mental health diagnoses. The DON confirmed that the PASARRs were not updated to include significant diagnoses, and necessary Level II screenings were not conducted, contrary to facility policy.
The facility failed to complete PASARR Level II evaluations for two residents with serious mental illnesses. One resident's Level I PASARR indicated the need for a Level II evaluation, which was not on record, while another resident had an incomplete Level I PASARR. The DON acknowledged these deficiencies, which were contrary to the facility's policy requiring PASARR evaluations for residents with significant mental health conditions.
A facility failed to obtain a physician's order for a resident's non-pressure wound treatment and did not apply treatments per professional standards. An undated bandage was observed twice on the resident's left arm, and the DON confirmed the lack of a physician's order until after surveyor observation. The facility's Wound Care policy requires adherence to physician orders and proper documentation, which was not followed.
A resident with pressure ulcers on both heels did not receive wound care as per physician orders. The wound care nurse used a dermal wound cleanser instead of normal saline and failed to apply Santyl moist gauze and the specified dressings. The DON confirmed the nurse did not check the orders before the procedure, highlighting a deviation from the care plan and facility policy.
Two residents in the facility were not administered oxygen therapy as ordered by their physicians. One resident received oxygen at 3.5 LPM instead of the prescribed 2 LPM, while another was found with the concentrator set at 5 LPM instead of 2 LPM. The discrepancies were confirmed by staff, and adjustments were made. The DON stated that nurses should verify and adjust oxygen flow rates according to physician orders at least once per shift.
A facility failed to follow Contact Precautions for a resident on isolation and did not ensure a clean nasal cannula for another resident using oxygen. A CNA entered a resident's room without PPE, despite signage indicating the need for it, and admitted to not wearing it due to time constraints and lack of information. Additionally, a resident's oxygen tubing was found on the floor, and the UM left it on the concentrator instead of disposing of it. The DON confirmed expectations for PPE use and disposal of contaminated equipment.
Failure to Promote Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to promote dignity during mealtime assistance for two residents who required support with eating. One resident with diagnoses including dysphagia, vascular dementia, and severe cognitive impairment was totally dependent on staff for all activities of daily living, including eating. Another resident with Parkinson's disease and dysphagia had fluctuating needs for eating assistance, but his care plan did not specify his mealtime support requirements. Observations revealed that staff provided mealtime assistance while standing rather than sitting at eye level, despite available chairs, and staff interviews confirmed this practice. The Central Supply Coordinator, who was also a CNA, acknowledged that staff should be seated at eye level for dignity and proper support. Additionally, multiple CNAs referred to residents requiring feeding assistance as "feeders" rather than using respectful terminology such as "assisted diners." The DON confirmed that this language was a dignity concern and that staff should use more respectful terms. The facility did not have a formal policy, procedure, or competency regarding CNA mealtime assistance, and the DON stated that such training should be included in CNA education. The facility's Resident Rights policy emphasized the importance of maintaining or enhancing resident dignity and respect, but staff practices and language did not align with these expectations.
Failure to Document Grievance Outcome and Resident Satisfaction
Penalty
Summary
The facility failed to follow its established grievance process for a resident who was cognitively intact and had a history of hemiplegia, hemiparesis, contracture of the right hand, congestive heart failure, and type 2 diabetes. The resident submitted two grievances regarding the demeanor and response time of a CNA, specifically noting issues with the CNA's tone of voice, raised voice, and delay in responding to call lights. The first grievance was documented with findings and communication of the outcome to the resident. However, for the second grievance, while corrective action was taken regarding the CNA's assignment, the facility did not document the outcome of the grievance or whether the resident was satisfied with the resolution. The grievance form for the second complaint was left incomplete, with the outcome section and satisfaction question unanswered, despite being signed by both the Social Services Director and the Administrator. Interviews confirmed that the Social Services Assistant received and discussed the grievance with the resident, but there was no documentation of follow-up or clarification with the resident regarding the resolution. The Administrator acknowledged the lack of documentation and that clarification should have been sought to determine if the grievance met criteria for a reportable event. The facility's policy requires a response to grievances within a reasonable time, which was not met in this instance.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders for a resident with a history of stroke complications, major depressive disorder, and chronic diastolic heart failure. The resident, who was cognitively intact, was observed on multiple occasions receiving oxygen at a flow rate of 4.5 liters per minute (LPM) via nasal cannula, despite physician orders specifying a rate of 2 LPM as needed for congestive heart failure. The resident was unable to confirm the correct flow rate, indicating a lack of awareness or communication regarding her prescribed oxygen therapy. Licensed Practical Nurse (LPN) A and the Unit Manager both acknowledged the discrepancy between the observed oxygen flow rate and the physician's orders. The LPN stated that oxygen therapy should be checked every shift and confirmed the resident's order for 2 LPM. The Unit Manager and the Director of Nursing reiterated that nurses are responsible for ensuring oxygen is administered at the correct rate, as oxygen is considered a medication. The facility's policy on oxygen administration requires adherence to physician orders, which was not followed in this instance, leading to the deficiency.
Failure in QAPI Implementation and Repeat Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices. Specifically, the facility had repeated concerns regarding the accuracy of Level I Pre-Admission Screening and Resident Reviews (PASARRs), referrals for Level II PASARRs, and obtaining non-pressure wound care orders and application of dressings per professional practice. These issues were identified during the last annual recertification survey in March 2023 and were again noted during the current recertification survey. The Administrator, who had been working at the facility since April 2024, was unaware of the previous deficiencies due to a change in ownership. It was confirmed that the facility did not have any Performance Improvement Plans in place at the time for the areas of concern regarding PASARRs and Quality of Care. The facility's Quality Assurance and Performance Improvement Plan, dated June 10, 2021, stated that the QA committee should be interdisciplinary and develop and implement appropriate plans of action to correct identified quality deficiencies, act on available data to make improvements, and monitor and evaluate the effectiveness of corrective actions.
Failure to Update PASARRs for Residents
Penalty
Summary
The facility failed to ensure the accuracy and updating of Level I Preadmission Screening and Resident Review (PASARR) for three residents, leading to deficiencies in their records. Resident #19 was admitted with multiple diagnoses, including Alzheimer's disease and major depressive disorder, but the PASARR dated 8/10/09 did not reflect these conditions. The Director of Nursing (DON) confirmed that the PASARR had not been updated to include these significant diagnoses, despite the facility's process requiring review and updates when new diagnoses are added. Similarly, Resident #7's PASARR did not indicate a mental illness despite the presence of depression and schizophrenia, and no Level II PASARR was completed. Resident #30's PASARR also failed to reflect diagnoses of major depressive disorder, generalized anxiety disorder, and psychotic disorder, and lacked a Level II PASARR. The DON acknowledged the oversight in updating the PASARRs and the absence of necessary referrals for Level II screenings, contrary to the facility's policy requiring such actions for residents with serious mental disorders.
Failure to Complete PASARR Evaluations
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASARR) Level II for two residents, as required by federal regulations. Resident #71, who was admitted with diagnoses including paranoid schizophrenia and schizoaffective disorder, had a Level I PASARR indicating the need for a Level II evaluation due to a serious mental illness. However, the facility did not have a Level II PASARR on record, and the Director of Nursing (DON) could not explain the absence of this documentation. The DON stated that the PASARR should have been completed by the hospital before admission and reviewed only if there was a diagnosis change, but this process was not followed. Resident #86, admitted with diagnoses such as Parkinson's disease and schizophrenia, had an incomplete Level I PASARR, missing the diagnosis page. The DON confirmed the incompleteness of the PASARR and acknowledged that a new Level I PASARR should have been completed due to the resident's serious mental health conditions. The facility's policy required the incorporation of PASARR Level II recommendations into the resident's care plan, but this was not adhered to, leading to deficiencies in the residents' assessments and care planning.
Failure to Obtain Physician's Order and Properly Document Wound Care
Penalty
Summary
The facility failed to obtain a physician's order for the treatment of a non-pressure wound on a resident's left arm and did not apply wound treatments according to professional standards. On two separate occasions, an undated bandage was observed on the resident's left arm near the elbow, indicating a lack of proper documentation and adherence to wound care protocols. The Memory Lane Unit Manager confirmed that nurses should date wound dressings to track when they were applied, but this was not done in this case. The Director of Nursing acknowledged that the resident's skin tear did not have a physician's order for treatment when initially observed and confirmed that the order was only obtained after the surveyor's observation. The facility's Wound Care policy requires that wound care procedures be performed according to physician orders and documented in the clinical record, which was not followed in this instance. The DON expected nurses to assess wounds, notify physicians for treatment orders, and follow those orders, including dating all dressings when applied.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with pressure ulcers on both heels, as per the physician's orders and care plan. The resident, who was admitted with multiple pressure injuries and was at risk for developing further ulcers, required specific wound care interventions. During an observation, the wound care nurse deviated from the prescribed treatment by using a dermal wound cleanser instead of normal saline and did not apply Santyl moist gauze or cover the wounds with the specified dressings. This deviation from the physician's orders was acknowledged by the wound care nurse and confirmed by the Director of Nursing (DON). The resident's medical record indicated a history of unstageable pressure wounds, dementia, muscle weakness, and atrophy, necessitating careful wound management. Despite the care plan's directive to follow physician orders for wound care, the nurse did not verify the orders before performing the procedure. The DON emphasized the importance of adhering to physician orders and acknowledged that it is best practice for nurses to have a copy of the orders during wound care to ensure compliance. The facility's policy also mandates that wound care be performed according to physician orders.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents, leading to deficiencies in respiratory care. Resident #36, who was admitted with multiple respiratory-related diagnoses, was observed receiving oxygen at a rate of 3.5 liters per minute (LPM) instead of the prescribed 2 LPM. This discrepancy was confirmed by the Unit Manager, who adjusted the oxygen concentrator to the correct setting. The Director of Nursing (DON) stated that nurses were expected to check oxygen settings at least once per shift, but ideally every time they entered the resident's room. Resident #152, with diagnoses including pulmonary fibrosis and COPD, was also found to be receiving oxygen at an incorrect flow rate. The resident was observed with the oxygen concentrator set at 5 LPM, contrary to the physician's order of 2 LPM. The resident was unaware of the correct setting and reported issues with the concentrator's functionality. The assigned nurse, RN A, confirmed the incorrect setting and adjusted it after verifying the physician's order. The DON acknowledged that nurses should verify and adjust oxygen flow rates according to physician orders at least once per shift. Both cases highlight a failure in the facility's protocol for administering oxygen therapy, as the oxygen flow rates were not consistently checked and adjusted according to physician orders. This oversight in monitoring and adjusting oxygen therapy could potentially lead to adverse effects on residents' health, as oxygen is a medication that requires precise administration. The facility's policy stated that oxygen should be administered under physician orders, except in emergencies, but this was not adhered to in these instances.
Infection Control Deficiencies in Contact Precautions and Oxygen Use
Penalty
Summary
The facility failed to adhere to Contact Precautions for a resident on isolation and did not ensure the use of a clean nasal cannula for another resident using oxygen. A Certified Nursing Assistant (CNA) was observed entering the room of a resident on Contact Isolation without performing hand hygiene or wearing the required personal protective equipment (PPE). Despite a sign on the resident's door indicating the need for a gown and gloves, the CNA admitted to not wearing the required PPE during multiple visits to the room, citing time constraints and a lack of information about the reason for the resident's isolation. The Director of Nursing (DON) confirmed that staff were expected to follow the Contact Precaution instructions and that CNAs had received education on infection control requirements. In a separate incident, a resident's oxygen tubing and nasal cannula were found on the ground in their room. The Unit Manager (UM) observed this and, after confirming with the resident that they did not need oxygen at that moment, turned off the oxygen concentrator but left the dirty nasal cannula and tubing on top of the machine. The DON later confirmed that oxygen tubing found on the floor should be disposed of immediately to prevent contamination. The facility's policy on Transmission-Based precautions indicated that signage and PPE should be provided near the entrance of the resident's room.
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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) |
|---|---|---|---|---|
| Solaris Healthcare East Orlando | 0.2 mi | — | 0 | 0 |
| Palm Garden Of Orlando | 1.8 mi | — | 0 | 0 |
| Conway Lakes Health & Rehabilitation Center | 2.9 mi | — | 4 | 0 |
| Avante At Orlando Inc | 3.2 mi | — | 3 | 0 |
| Westminster Baldwin Park | 3.5 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.