Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to promote dignity related to privacy of catheter
drainage bag for 1 of 1 resident reviewed for dignity, out of a total sample of 36 residents, (#69).
Findings:
Resident #69 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory
reaction due to cystostomy catheter, neuromuscular dysfunction of bladder and retention of urine.
Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of
11/06/22 revealed resident #69 had a Brief Interview for Mental Status score of 11 out of 15 which indicated
he had moderate cognitive impairment. The document indicated the resident used an indwelling catheter
and had a diagnosis of neurogenic bladder.
A care plan for an indwelling catheter with neurogenic bladder was initiated on 11/01/22. Interventions
included to position catheter bag and tubing below the level of the bladder and away from entrance room
door.
On 1/08/23 at 10:09 AM, 1/08/23 at 12:47 PM, and 1/09/23 at 9:38 AM, resident #69 was observed in bed
with a catheter drainage bag hanging on the side of the bed closest to the door and facing the open
doorway. The bag was uncovered and dark colored urine was visible in the drainage bag.
On 1/09/23 at 9:44 AM, Licensed Practical Nurse (LPN) A confirmed resident #69 had an indwelling
catheter. She entered the room and observed the catheter drainage bag and tubing hanging on the side of
the bed facing the open door. LPN A stated the Certified Nursing Assistant (CNA) was responsible for
placement of the drainage bag which should be in a privacy bag or positioned away from the door.
On 1/09/23 at 10:07 AM, CNA B stated resident #69 was on her assignment 1/08/23 and 1/09/23. She
confirmed he had an indwelling catheter and she was responsible for placement of the catheter tubing and
drainage bag. CNA B explained the catheter drainage bag should be in a privacy bag but she did not have
one. She stated she did not think to turn the bag so it could not be seen from the door or to hang it on the
opposite side of the bed away from the open doorway.
On 1/10/23 at 4:15 PM, the Director of Nursing (DON) stated if a resident had a catheter, the drainage bag
should be in a privacy bag even when hanging on the bed. She stated if a staff member needed a privacy
bag for a resident, all they had to do was get one from central supply. She explained
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
105480
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
alternate placement on the bed was not necessary as the facility had plenty of privacy bags.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 2 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to notify the physician of change in condition for
1 of 1 resident reviewed for change of condition from a total sample of 36 residents, (#52).
Findings:
Resident #52 was admitted on [DATE], discharged to the hospital on [DATE], and re-admitted to the facility
on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, and urinary tract infection
(UTI).
Review of the resident's medical record revealed the quarterly 5-day Minimum Data Set (MDS) assessment
with reference date (ARD) 12/16/2022 identified the resident was moderately cognitively impaired, required
extensive assistance for activities of daily living, and the resident received antipsychotic medications for 5
of 7 days in the look back period.
The resident's care plan for psychotropic medications dated 9/07/22 included monitoring for side effects
and effectiveness of psychoactive medications every shift.
Resident #52's active medication orders included Valproate Sodium oral solution, 500 milligrams (mg) by
mouth three times a day for seizures, Benzotropine Mesylate 0.5 mg tablet by mouth two times a day for
extrapyramidal symptoms, and Risperidone oral solution 2 mg one time a day by mouth for paranoid
schizophrenia.
On 1/09/2023 at 10:23 AM, resident #52's family member said the resident hallucinated and saw snakes
the last few days. He explained the resident hallucinated before when she had a UTI.
On 1/10/2023 at 9:35 AM, resident #52 was observed visibly distressed and pointed to a wheelchair. The
resident said she saw snakes for approximately one week and stated, they're over there, nobody believes
me.
On 1/10/2023 at 10:32 AM, the resident's assigned nurse, Licensed Practical Nurse (LPN) F on the 7 AM to
3 PM shift said resident #52 was regularly included in her assignment. LPN F explained she was recently
informed the resident was seeing snakes. She said hallucinations were not a normal condition for the
resident.
A review of resident #52's Medication Administration Record (MAR) showed orders for nurses to monitor
side effects and behaviors including visual disturbances and hallucinations. The MAR dated 1/01/2023 to
1/10/2023, on the 7 AM to 3 PM signed by nurses did not indicate the resident had visual disturbances or
hallucinations.
On 1/10/2023 at 3:39 PM, LPN G who worked the 3 PM to 11 PM shift said she received report from the
outgoing nurse, LPN F that resident #52 was hallucinating and seeing snakes. She explained the physician
had not been notified and change in condition form had not been completed. LPN G said hallucinations for
resident #52 was a change.
On 1/10/2023 at 4:08 PM, the Director of Nursing explained when a resident experienced a change of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 3 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
condition, the expectation was for the nurse to complete an assessment, and notify the physician and
family. The DON said the new onset of hallucinations was considered a change in condition and the day
shift nurse should have completed that process.
The facility policies and procedures titled, Notification of Change In Condition dated November 30, 2014,
revised December 16, 2020 read, the nurse to notify the attending physician and resident representative
when there is a(n) significant change in the patient/resident's physical, mental, or psychosocial status,
acute condition, exacerbation of a chronic condition, the nurse to complete an evaluation of the
Patient/Resident. Document evaluation in the medical record, document resident/patient change in
condition on 24 Hour Report, and Complete SBAR as indicated.
Event ID:
Facility ID:
105480
If continuation sheet
Page 4 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to refer residents with a newly evident mental disorder for
Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 2 of 3
residents reviewed for PASRR, out of a total sample of 36 residents, (#21 and #76).
Findings:
1. Resident #21 was admitted to the facility on [DATE] with diagnoses including insomnia, hypertension,
transient cerebral ischemic attack, acquired absence of right leg above knee and other recurrent depressive
disorders.
Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of
12/02/22 revealed resident #21 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated
she had moderate cognitive impairment. The document indicated her active diagnoses included depression
and schizophrenia.
Review of resident #21's care plan revealed a behavior care plan initiated 2/01/21 which indicated the
resident exhibited behavior problems related to schizoaffective disorder of the bipolar type. Interventions
included education of the resident on successful coping and interaction strategies, minimize the potential
for disruptive behaviors and intervene as necessary to protect the rights and safety of others.
Review of resident #21's electronic medical record (EMR) revealed a diagnosis of schizoaffective disorder,
bipolar type with an onset date of 10/14/20. The record contained a Level I PASRR screening form dated
1/18/22 which did not indicate the resident had a mental illness (MI) or suspected MI. The record did not
contain a Level II PASRR screening form.
2. Resident #76 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder,
generalized anxiety disorder and recurrent major depressive disorder.
Review of the MDS quarterly assessment with ARD 09/30/22 revealed resident #76 had a BIMS score of
15 of 15 which indicated he was cognitively intact. The document indicated his active diagnoses included
depression and schizophrenia.
Review of resident #76's care plan revealed a behavior care plan initiated 7/08/21 which indicated the
resident did not cooperate with care related to adjustment to nursing home, cardio vascular accident and
mental illness. Interventions included education of the resident of possible outcome of not complying with
treatment or care, maintain consistency in timing of care as much as possible and praise the resident when
behavior was appropriate.
Review of resident #76's EMR revealed a diagnosis of schizoaffective disorder, bipolar type with an onset
date of 6/26/21. The record contained a Level I PASRR screening form dated 6/26/21 which did not indicate
the resident had a MI or suspected MI. The record also contained an updated Level I PASRR dated 9/15/22
which did not indicate the resident had a MI or suspected MI. The record did not contain a Level II PASRR
screening form.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 5 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 1/11/23 at 9:30 AM, the Social Services Director (SSD) stated the admissions department obtained the
initial PASRR screening forms from the hospital prior to admission. He explained the SSD and nursing team
reviewed the PASRR upon admission. If the form was incorrect, the Director of Nursing (DON) and SSD
would complete an updated PASRR. He clarified if a resident was admitted without a MI diagnosis and it
became evident later the resident had a MI diagnosis, the SSD would complete an updated Level I PASRR.
The resident would then be referred for a Level II PASRR screening. The SSD was unsure as to whether
resident #21 or resident #76 had an updated Level I PASRR screen or had been referred for a Level II
PASRR screening.
On 1/11/23 at 1:46 PM, the SSD verified an updated Level I PASRR was not completed for either resident.
He explained neither resident had been referred for a Level II PASRR screening since they were not
identified as having mental illness diagnoses on the Level I PASRR. The SSD stated he was not aware
either resident had MI diagnosis.
The facility's policy and procedure for Preadmission Screening and Resident Review (PASRR) dated
11/08/21 read, If it is learned after admission that a PASRR Level II screening is indicated, it will be the
responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the
screening and obtain the results.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 6 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Rosewood
3920 Rosewood Way
Orlando, FL 32808
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for 1 of 3 residents reviewed for activities of a total sample of 36 residents, (#49).
Findings:
Resident #49 was admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis, mood
disorder, major depressive disorder, coronary artery disease, end stage renal disease, and acute kidney
disease.
Review of resident #49's medical record revealed the admission Minimum Data Set (MDS) with assessment
reference date (ARD) 11/21/2022 identified the resident was cognitively intact and required extensive
assistance for activities of daily living (ADL). The MDS completed by the Community Life Director for
preferences of activities indicated it was very important for the resident to listen to preferred music, go
outside, and do group activities.
On 1/09/2023 at 10:30 AM, resident #49 said he was not provided information for facility activities.
Review of resident #49's care plan did not include a plan of care for activities.
On 1/09/2023 at 4:10 PM, the Community Life Director stated she was responsible for completing the MDS
activities preferences and updating residents' plan of care. She acknowledged resident #49 did not have a
care plan for activities.
The facility policy and procedures, titled Plans of Care effective 11/30/14, revised 9/25/2017 read, the
interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is
oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial
well-being.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the January 11, 2023 survey of AVIATA AT ROSEWOOD?
This was a inspection survey of AVIATA AT ROSEWOOD on January 11, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIATA AT ROSEWOOD on January 11, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.