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 0635
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure admission physician orders for immediate care of
surgical sites were obtained for 1 of 2 residents reviewed of a total sample of 7 residents, (#2).
Residents Affected - Few
Findings
Resident #2, a [AGE] year-old female was admitted to the facility on [DATE], and readmitted on [DATE]. Her
diagnoses included fracture of upper and lower end of the right fibula, fracture lower end of the right tibia,
and physeal fracture of the lower end of the right fibula.
Review of the resident's Medical Certificate for Medicaid Long-Term Care Services And Patient Transfer
Form (3008) dated 11/23/24 revealed the resident's primary diagnosis was right ankle fracture, and
documentation noted the resident had sutures to her left lower extremity, and an ace bandage wrap to her
right lower extremity.
The hospital's Brief op (operative) note dated 11/19/24 revealed an operative fixation of the right ankle and
removal of external fixator was performed on resident #2.
The Orthopedic Trauma Surgery Discharge Instructions printed on 11/23/24 read, Wound Care/Dressings:
Aquacel dressings should stay on for 5 days after surgery . After Aquacel is removed, perform daily (and as
needed) dressing changes with gauze and tape (or ACE wrap) .Do not place any ointments, lotions, or
creams on your surgical incisions. Do not submerge surgical sites in water.
Aquacel is a hydrofiber dressing that is used to treat wounds .has been shown to be effective in .surgical
wounds. (retrieved on 12/05/24 from pubmed.ncbi.nlm.nih.gov).
A review of resident #2's Admission/readmission Data Collection document dated 11/23/24, revealed the
resident had a surgical wound on her left lateral knee with 11 stitches, the lower leg had two stitches, and
there was a cast on her right lower leg.
Clinical record review of the resident's active and discontinued physician orders revealed no orders for the
surgical sites, until 11/25/24. On that date, the physician orders were, monitor surgical wound for s/s
(signs/symptoms) of infection, cleanse surgical wound on left lower leg with normal saline, pat dry and
cover with dry dressing every day shift, cleanse surgical wound on left lateral knee with normal saline, pat
dry and cover with dry dressing every day shift.
On 11/25/24 at 1:30 PM, Licensed Practical Nurse (LPN) B, acknowledged she was resident #2's primary
nurse. LPN B stated the resident was readmitted to the facility on [DATE] and had a surgical wound
(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 5
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
11/25/2024
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 0635
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
with staples. She stated the resident would be seen by the wound care physician and continued with the
hospital discharge orders for wound care. LPN B stated she had not completed the resident's dressing as
yet.
On 11/25/24 at 2:08 PM, resident #2 was sitting up in bed watching television. The resident uncovered her
left leg to show staples from her knee down with no dressing present. The area/staples were open to air,
and her right leg was wrapped with bandage wrap.
On 11/25/24 at 4:22 PM, the Regional Nurse reviewed the resident's physician orders. She acknowledged
the resident was readmitted to the facility on [DATE], and no orders were identified to address the surgical
site (s) until 11/25/24.
On 11/25/24 at 4:38 PM, the Director of Nursing (DON) explained when a resident was admitted to the
facility, the admission nurse reviewed the resident's hospital's discharged orders, and would enter the
orders into the facility's electronic medical record (EMR) for the individual resident. She stated that normally
residents came to the facility with physician orders for wound care, and if there were no orders, the nurse
needed to notify the physician and obtain orders. Resident #2's clinical records were reviewed with the
DON. She acknowledged the resident was readmitted to the facility on [DATE], and orders for surgical
site(s) care was not obtained and entered into the EMR until 11/25/24. She said the expectation was that
admission physician orders should have been in place, and hospital's orders for the surgical site should
have been transcribed to the resident's EMR.
The facility's policy Physician Orders with effective date of 11/30/2014, and revision date of 3/03/2021 read,
The center will ensure that Physician orders are appropriately and timely documented in the medical
records. admission Orders: Information received from the referring facility or agency be reviewed, verified
with the physician and transcribed to the electronic medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 2 of 5
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
11/25/2024
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
observation, interview and record review, the facility failed to develop a comprehensive individualized care
plan for 1 of 3 residents of a total 7 residents, (#5)
Findings:
Resident #5 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major
depressive disorder, anxiety, history of falls, and hypertension. On 10/3/24 she was re-hospitalized for chest
pain and then returned to the facility on [DATE].
Review of resident's care plan on 11/25/24 revealed a care plan with only one focus which was initiated on
10/24/24. The focus noted the resident had nutritional problem or potential nutritional problem related to
hypertension, anemia, major depressive, hemiplegia, hypotension, morbid obesity, venous thrombosis, iron
deficiency anemia, anxiety disorder, muscle weakness, and Mini Nutritional Assessment score reflects risk
for malnutrition.
Review of a care plan initiated on 6/26/24 revealed the care plan had been cancelled following resident's
transfer to the hospital. The care plan initiated on 6/26/24 included risk for falls related to deconditioning,
use of antidepressant medications related to depression, use of anticoagulation therapy related to history of
deep vein thrombosis and risk for acute pain related to impaired mobility.
Review of resident #5's Minimum Data Set (MDS) history revealed a MDS Discharge Return Not
Anticipated initiated on 10/3/24 which was followed by a MDS Discharge Return Anticipated on 10/3/24.
Interview with the MDS coordinator at 11:45 am on 11/25/24 revealed the previous MDS coordinator initially
noted the resident as discharge not anticipated which canceled the care plan. The resident was supposed
to be listed as discharge return anticipated. The MDS coordinator agreed the resident went without an
accurate care plan from 10/21/24 till 11/25/24.
Review of the facility's Plan of Care policy and procedure revised on 9/25/17 revealed that an individualized
person centered plan of care may include resident's strengths, services to attain residents highest
practicable physical, mental and psychosocial well-being as required by state and federal regulatory
requirements.'
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 3 of 5
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
11/25/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to follow physician orders for surgical pin site dressing for 1 of
2 residents reviewed for surgical wounds, of a total sample of 7 residents, (#1).
Residents Affected - Few
Findings:
Resident #1, a 49- year-old female was admitted to the facility on [DATE]. Her diagnoses included anterior
dislocation of proximal end of tibia, right knee, generalized weakness, pain in right knee, diabetes type II,
cardiac murmur, depression, and anxiety disorder.
Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15 out of 15. The
assessment noted the resident was dependent on staff assistance for activities of daily living, required
substantial/maximal assistance of staff for chair/bed-to chair transfer, and had surgical wound(s).
Review of the resident's clinical records revealed a physician order dated 3/05/34, to paint pin site with
Betadine, pat dry, cover with dry gauze and secure with tape daily. This order was discontinued on 3/06/24.
Review of the resident's Treatment Administration Record (TAR) revealed a blank space on 3/06/24, and
there was no documentation to indicate the treatment was completed. Physician order on 3/07/24, noted to
clean the pin site(s) with hydrogen peroxide and normal saline, pat dry, cover with dry gauze, and secure
with tape every day shift. This order was discontinued on 4/11/24. Review of the resident's TAR revealed
blank spaces on 3/08/24, 3/15/24, and 3/28/24. There was no signature or documentation to indicate the
physician's orders were completed.
On 3/09/24, and on 3/24/24, the code 2 was documented, indicating the resident refused, and on 3/12/24
the code 3 was documented, indicating a Leave Of Absence. Documentation to indicate the physician was
notified of the resident's refusal on 3/09/24, and 3/24/24 was not identified.
On 11/25/24 at 1:41 PM, the resident's clinical records were reviewed with the Assistant Director of
Nursing/Unit Manager (ADON /UM). She acknowledged the blank spaces on the resident's TAR for the
dates identified, and explained there should have been something documented, and the spaces should not
be left blank. The ADON/UM said that if the resident refused the treatment, a code should be placed, and
the TAR should be signed by the nurse.
On 11/25/24 at 3:15 PM, the Director of Nursing (DON) stated that when treatment was provided the
residents' TAR should be signed by the nurse. The resident's TAR was reviewed with the DON, she
acknowledged that blank spaces were on the TAR for the dates identified, and that a progress note
regarding the treatment could not be identified for the dates noted.
As per the DON, the facility did not have a policy to address documentation on the residents' TAR. However,
the facility's policy Administering Medications revised April 2019 read, Topical medications used in
treatments are recorded on the resident's treatment record (TAR).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 4 of 5
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
11/25/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure medications were administered per
professional standards for 1 of 7 residents, (#3).
Findings
Resident #3, an 81- year-old female was admitted to the facility on [DATE], with her most recent
readmission on [DATE]. Her diagnoses included end stage renal disease, diabetes type II, hypertension,
chronic pain, and major depressive disorder.
On 11/25/24 at 9:57 AM, a medication cup with medications was observed on resident #3's tray table. The
resident stated the medications were left there by the nurse, and she would be take the medication
momentarily. The resident stated she had breakfast and the nurse bought the medications in, but she fell
asleep before taking the medications.
On 11/25/24 at 10:00 AM, observation of the cup with medications on the resident's tray table was
conducted with Registered Nurse (RN) A the resident's assigned nurse. RN A acknowledged the cup with
the medications was on the resident's tray table and confirmed she gave the resident her medications.
Record review of the resident's Medication Administration Record (MAR) revealed the resident's
medications were documented as given at 9:26 AM. This was acknowledged by RN A, who stated she was
aware medications were not to be left at the resident's bedside. RN A verbalized she was called away from
the resident for an emergency, but did not take the medications out with her, and forgot to go back and
check on the resident.
Review of the MAR revealed medications administered by RN A at 9:26 AM included Bumex 2 milligram
(mg) for edema, [NAME]-Vita tablet for end stage renal disease, Sevelamar Carbonate 800 mg x 3 tablets,
Ocular Vitamin for macular degeneration, Fish oil 500 mg for high triglyceride, and Cetirizine for sinus
congestion.
On 11/25/24 at 10:40 AM, the Director of Nursing (DON) stated medications should not be left at the
resident's bedside, and nurses should ensure medications were taken by the resident before leaving. She
stated that if the resident refused their medications, and wanted the nurse to come back, the nurse should
take the medications with her. If responding to an emergency, the medications should be taken out with the
nurse, and not left at the resident's bedside.
On 11/25/24 at 3:24 PM, the Regional Nurse stated the expectation was that nurses should watch the
resident take their medications, and medications should not be left at the resident's bedside.
The policy Administering Medications revised April 2019 read, For residents not in their rooms or otherwise
unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication
pass, the nurse will return to the missed resident to administer the medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105480
If continuation sheet
Page 5 of 5
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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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F635 - Admission orders
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 November 25, 2024 survey of AVIATA AT ROSEWOOD?
This was a inspection survey of AVIATA AT ROSEWOOD on November 25, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIATA AT ROSEWOOD on November 25, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.