Winter Garden Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Winter Garden Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 25, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate supervision for cognitively impaired residents to prevent falls with fractures for 2 of 7 residents reviewed for falls, of a total sample of 8 residents, (#2 & #3). The lack of adequate supervision contributed to the residents sustaining fractures, hospitalization s, and decline in their functional range of motion. Findings: 1. Review of the medical record noted resident #2 was a [AGE] year-old, admitted to the facility on [DATE]. She was hospitalized on [DATE], readmitted on [DATE], and hospitalized again on 12/15/22 with readmission on 1/19/23. […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2021

  Based on observation, interview and record review, the facility failed to ensure the dishwashing machine was operating to properly wash and sanitize resident dishware, and failed to ensure sanitizing strips for the 3-compartment sink were not expired. Finding: 1. On [DATE] at 10:28 AM, the dishwashing machine revealed a low temperature with the wash temperature at 120°Fahrenheit (F) and rinse at 120°F. The test strip used for the chlorine-based sanitizer was not readable. The wash and rinse water were very sudsy. There was no sanitizer solution present. The Food Service Director (FSD) said that they washed the dishes yesterday with pot and pan soap when the correct soap was not available. She said she had just brought out a bottle of sanitizer. The label read rinse agent. […]

• No harm, potential for more than minimal, patternF684May 21, 2026

  Based on interview, and record review, the facility failed to provide pharmaceutical services, consistent with professional standards of practice, to ensure safe medication administration for three residents reviewed for anticonvulsant medications, of a total sample of 10 residents, (#1, #2, and #3).Findings:1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (one-sided weakness and paralysis) following a cerebral infarction (stroke), epilepsy, dementia, dysphagia (trouble swallowing) and type 2 diabetes mellitus.Review of a physician progress note on 1/13/26 revealed the resident had an episode of unresponsiveness to voice or light touch and he would only open his eyes to a strong rub on the chest… […]

• No harm, potential for more than minimal, patternF812Feb 7, 2025

  Based on observation, record review, and interview, the facility failed to determine if potentially hazardous foods were at a safe cold holding temperature prior to distribution. Findings: On 2/07/25 at 11:30 AM, during observation of the lunch trayline, the facility cook initiated taking temperatures of the hot food items on the steam table. At 11:45 AM, the cook stated she had completed taking all of the food holding temperatures and the Certified Dietary Manager (CDM) instructed the staff to start the lunch trayline. There was a small table across from the steam table which had beverages including milk, a potentially hazardous food. Review of the facility's food holding temperature log for February 2025 revealed the cold holding temperature for the milk had not been obtained. […]

• No harm, potential for more than minimal, patternF835Feb 7, 2025

  Based on interview, and record review, the administration failed to ensure safe water temperatures from 2 of 2 boiler rooms that supplied hot water to all resident areas were adequately monitored and failed to oversee environmental services to ensure resident room repairs were conducted routinely. Findings: On 2/03/25 at 3:15 PM, during an interview with resident #62, she stated the bath water the Certified Nursing Assistant (CNA) brought to her bedside that day from the bathroom was too hot and the CNA had to make it cooler. She could not recall the CNA's name. At 3:25 PM, the hot water from the faucet in the bathroom was felt for temperature, but the water was too hot to hold a hand under the water for more than a few seconds. […]