Orlando Health Center for Rehabilitation

In the surveyor’s words

From the most serious findings on record at Orlando Health Center for Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision and a safe environment in the locked Memory Care Unit to prevent a physically and cognitively impaired resident from suffering falls with major injuries, for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). These failures contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. There was likelihood resident #1 suffered excruciating pain as a result of her bone fractures, and she required sedation to control her symptoms of pain and extreme agitation at the end of her life. On [DATE] at approximately 5:00 PM, resident #1 was left unattended on the outdoor patio of the Memory Care Unit. […]

• Immediate jeopardy, isolatedF741Jun 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure sufficient staff were assigned to the Memory Care Unit to adequately supervise and monitor the behaviors of physically and cognitively impaired residents to prevent falls with major injuries, for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). This failure contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. There was likelihood resident #1 suffered excruciating pain as a result of her bone fractures, and she required sedation to control her symptoms of pain and extreme agitation at the end of her life. […]

• Immediate jeopardy, isolatedF835Jun 17, 2022

  Based on observation, interview and record review, the facility failed to effectively utilize its resources to develop appropriate, individualized fall prevention interventions; failed to schedule sufficient staff to provide adequate supervision and monitoring; and failed to maintain a safe environment in the Memory Care Unit for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). These failures contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. […]

• No harm, potential for more than minimal, patternF607Jun 10, 2021

  Based on interview and record review, the facility failed to implement the Abuse Prohibition Policy and Procedure related to reporting of abuse for 6 of 6 residents reviewed for abuse, (#8, #16, #361, #41, #20, #43) and failed to initiate interventions to protect 40 of 40 vulnerable residents in the Memory Care Unit. Findings: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed resident #16 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated she was unable to complete the interview. The assessment revealed her cognitive skills for daily decision making were severely impaired. […]

• No harm, potential for more than minimal, patternF636Jun 10, 2021

  Based on record review and interview, the facility failed to complete Minimum Data Set (MDS) comprehensive admission assessments for 13 residents, (#263, 264, 265, 260, 113, 269, 270, 271, 275, 276, 4, 277, 28) and discharge assessments for 10 residents, (#7, 266, 267, 268, 272, 273, 274, 265, 18, 271) within the required timeframe for 21 residents reviewed for assessments of a total sample of 50 residents. Findings: Review of the medical records revealed the following 13 residents were admitted on the following dates and did not have admission comprehensive assessment completed within the required 14-day period, residents #263, #264, and #265 were admitted on [DATE], resident #260 was admitted on [DATE], residents #113 and #269 were admitted on [DATE], residents #270 and #271 were… […]