Rehabilitation Center of Orlando

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 9, 2023

  Based on observation, interview, and record review, the facility failed to implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death. […]

• Actual harm, isolatedF686Mar 31, 2022

  Based on observation, interview and record review, the facility failed to provide care and services to prevent the development of a pressure ulcer and shear injury (#10), and failed to ensure application of pressure reducing devices to prevent further skin breakdown (#22 & #55) for 3 of 7 residents reviewed for pressure ulcers of a total sample of 44 residents. The facility's failure to implement preventative interventions consistent with resident #10's risk for skin breakdown, and failure to identify areas of skin injury according to accepted standards of practice resulted in actual harm, development of a stage 3 pressure ulcer to the right ear. Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF867Jan 11, 2024

  Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to respiratory care, pressure ulcer care, nurse staffing postings and kitchen sanitation. Findings: Cross reference F686, F695, F732 and F812 Review of the facility's survey history revealed repeat deficiencies related to the delivery of oxygen per physician orders, provision of preventive care for pressure ulcers, retaining and posting of daily nurse staffing sheets and the cleanliness and sanitation of the kitchen during the current survey ending 1/11/24. […]

• No harm, potential for more than minimal, patternF837Jun 18, 2026

  Based on observation, interview, and record review, the facility's Governing Body failed to timely ensure complete, consolidated, accurate accounting of personal funds, transactions, and balance transfers were provided upon and after transfer of ownership for 3 of 3 residents reviewed for Resident Rights, of a total sample of three residents, (#1, #2, #3). Findings:On 6/18/26 at 11:15 AM, resident #1, a cognitively impaired [AGE] year-old female resident was observed sitting on her bed in her room. […]

• No harm, potential for more than minimal, patternF584Jan 22, 2026

  Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to ensure two of two shower rooms were clean, sanitary, and homelike on one of two units, (East Wing), failed to ensure flooring in the back hallway was in good repair and homelike on one of two units, (West Wing), and failed to ensure 4 of 35 residents' rooms on the [NAME] Wing were maintained in good repair and in homelike condition, (#15, #27, #28, and #29).Findings: Cross reference F867 Observations during tour of the facility on 1/21/26 between 11:18 AM, and 11:30 AM revealed in room [ROOM NUMBER], the lower portion of the entrance door exhibited warping and breakage with sharp edges. […]