Courtyards of Orlando Care Center and Rehab

In the surveyor’s words

From the most serious findings on record at Courtyards of Orlando Care Center and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600May 26, 2023

  Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect by failing to verify the identity, credentials, and licensure of individual prior to employment as a Licensed Practical Nurse, (LPN) providing care to 68 residents using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A to worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. […]

• Immediate jeopardy, patternF607May 26, 2023

  Based on interview, and record review, the facility failed to implement policies and procedures to prevent medical neglect by failing to verify identification, and licensure of Employee A prior to employment as a Licensed Practical Nurse (LPN)providing care and services to 68 residents during 16 shifts using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. […]

• Immediate jeopardy, patternF835May 26, 2023

  Based on interview, and record review, the facility's administration failed to use its resources effectively to ensure policies and procedures were implemented to prevent medical neglect placing 68 residents in the facility at risk by not verifying identification and licensure of an individual prior to employment as a Licensed Practical Nurse (Employee A) assigned to provide nursing care and services for 68 residents on 16 shifts while working in the capacity of a LPN without a valid license. The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. […]

• Immediate jeopardy, isolatedF689Jun 6, 2022

  Based on observation, interview, and record review, the facility failed to maintain a secure environment in the locked memory care unit and failed to provide adequate supervision to prevent a physically and cognitively impaired resident from exiting the facility, for 1 of 6 residents reviewed for elopement, of a total sample of 16 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility at night, unsupervised, there was high likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. On 5/26/22 at 9:03 PM, resident #1 pushed open an unlocked, alarmed fire exit door on the secure memory care unit. […]

• Immediate jeopardy, isolatedF689Mar 12, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of 1 of 9 residents reviewed for elopement risk, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised for 7 hours, there was high likelihood she could have fallen, become lost or been hit by a car. On [DATE] at 6:45 PM, resident #1 exited the facility unsupervised without staff knowledge. She walked past the secure memory care exit door by following the Receptionist D and through the front exit door which Receptionist D opened, not realizing she was a resident. […]