Regents Park of Winter Park

In the surveyor’s words

From the most serious findings on record at Regents Park of Winter Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 13, 2024

  Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect to prevent a fall with major injury (#3); and neglected to implement care directives to promote safety during a transfer procedure, (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. […]

• Immediate jeopardy, isolatedF689Dec 13, 2024

  Based on observation, interview, and record review, the facility failed to follow its policies and procedures and accepted standards of practice to prevent an avoidable fall from a full body mechanical lift (#3); and ensure use of the appropriate type of mechanical lift to meet assessed needs (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. […]

• Immediate jeopardy, isolatedF689Aug 8, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision and failed to respond appropriately to a door alarm for 1 of 15 residents reviewed for elopement, of a total sample of 15 residents, (#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 unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. […]

• Actual harm, isolatedF686Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 2 of 3 residents reviewed for pressure ulcers, of a total sample of 45 residents, (#214 and #17). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #214 was identified to have 2 new facility acquired pressure ulcers/injury identified 15 days after being admitted to the facility. The resident had one stage II pressure wound on her left buttock and an unstageable pressure wound on her sacrum. […]

• Actual harm, isolatedF624Jan 24, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement a safe discharge plan to ensure a resident would not be discharged to an unlicensed group home for 1 of 4 sampled residents, (#1). The facility's failure to develop a safe/reasonable discharge plan to meet the resident's care needs and have a process in place to assess the safety of the discharge location resulted in psychosocial harm to resident #1. Based on the resident's severe cognitive impairment and inability to express his response, and using the reasonable person concept, the resident would experience anxiety, agitation, distress, and depressed mood when discharged to an unlicensed group home that was unsafe and incapable of meeting his needs. […]