Parkview Rehabilitation Center at Winter Park

In the surveyor’s words

From the most serious findings on record at Parkview Rehabilitation Center at Winter Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 23, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a physically and cognitively impaired resident from exiting the facility and failed to ensure staff responded timely to exit door alarms to ensure the safety of 1 of 4 residents reviewed for elopement of a total sample of 7 residents, (#1). While resident #1 was outside the facility unsupervised, there was a likelihood he could have fallen from his wheelchair, been accosted by unknown persons, or been hit by a car. On 7/11/22 at 4:36 AM, the facility failed to prevent resident #1, a physically and cognitively impaired resident, from exiting the facility unsupervised. […]

• Immediate jeopardy, isolatedF689Jul 21, 2021

  Based on observation, interview and record review, the facility failed to prevent an avoidable fall for 1 of 13 residents reviewed for falls out of a total sample of 47 residents, (#235). This failure resulted in resident #235 falling from her bed and sustaining injury and subsequent death. On [DATE] at approximately 5:45 AM, an agency staff, Certified Nursing Assistant (CNA) E provided incontinence care to resident #235 without assistance. CNA E rolled the resident onto her left side, to secure the incontinence brief and the resident fell out of bed onto the floor, face first. The resident was transferred to the hospital where she was intubated and admitted to the intensive care unit. She was diagnosed with a severe head wound, brain bleed and brain shift. […]

• No harm, potential for more than minimal, patternF842Aug 14, 2026

  Based on interview, and record review, the facility failed to accurately document Activities of Daily Living (ADLs) provided for 2 of 4 residents reviewed for ADLs, out of a total sample of 8 residents, (#1 and #2). Findings: 1. Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/24/26. Her diagnoses included Alzheimer's disease, dementia, and cerebrovascular disease. Review of resident #1's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/30/26 revealed a Brief Interview for Mental Status (BIMS) exam was not obtained because the resident was rarely or never understood. […]

• No harm, potential for more than minimal, patternF755Aug 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for 5 of 5 residents reviewed for medication administration, of a total sample of 9 residents, (#5, #6, #7, #8, & #9). Findings: On 8/08/24 at 12:07 PM, Licensed Practical Nurse (LPN) A was at her medication cart preparing medications. The LPN stated she was still giving her morning medications and had three more residents to give morning medications to. The 1st floor Unit Manager (UM), and Registered Nurse (RN) Supervisor were seen sitting at the nurse's station. LPN A stated the UM was aware she was still giving morning medications after 12:00 PM. […]

• No harm, potential for more than minimal, patternF656Sep 8, 2023

  Based on observation, interview, and record review, the facility failed to implement nutrition / hydration care plans that included physician orders for thickened liquids for 3 of 4 residents reviewed for dietary services, out of a total sample of 4 residents, (#4, #6, and #8). Findings: On 9/07/23 at 10:17 AM, Cook D stated residents' meal trays were prepared according to pre-printed diet slips that reflected the type of diet, required food texture, and consistency of fluids. She explained the kitchen stocked large, pre-mixed containers of mildly thickened water (nectar consistency) and moderately thickened water (honey consistency) from which kitchen staff dispensed the correct fluid into cups at mealtimes. […]