Winter Haven Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF838Jun 18, 2026

  Based on record review, and interviews, the facility failed to ensure the facility wide assessment included information related to staff education and competencies needed for the care of residents with different acuities, and the number of staff needed for each shift.Findings included: A review of the facility's staffing data report, reported to the Centers for Medicare and Medicaid services (CMS), revealed excessively low weekend staffing was triggered for the quarter of October 1, 2026 to December 31, 2026. On 6/18/26 at 11:45 a.m., an interview with the Staffing Coordinator was conducted. She said she staffed the facility by what the opening census was. […]

• No harm, potential for more than minimal, widespreadF880Jun 18, 2026

  Based on observations, interviews, and record review, the facility failed to implement an effective infection control program related to: 1) ensuring precautions were initiated for two residents (#22 and #28) out of two residents diagnosed with a multi-drug resistant organism (MDRO), 2) ensuring one resident (#29) out of 18 residents with enhanced barrier precautions (EBP) had signage posted outside of the room; 3) ensuring hand hygiene was performed by staff members on one unit (300) out of three units while passing meal trays, 4) assisting residents on one unit (300) with hand hygiene prior to meal service, 5) cleaning and disinfecting multi-use medical devices before or after used during medication administration, 6) to ensure hand hygiene was performed during medication administration,… […]

• No harm, potential for more than minimal, patternF645Jun 18, 2026

  Based on interviews and record review, the facility failed to ensure the Level 1 Pre-admission Screening and Resident Reviews (PASRR) were accurate for four residents (#2, 22, 26, and 29) out of 11 residents sampled. Findings included: 1. A review of Resident #26's admission record revealed an admission date of 4/12/24, with a readmission admission date of 12/16/25. The admission record revealed diagnoses to include; generalized anxiety disorder (onset 8/15/24), dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 8/1/25), bipolar disorder, unspecified (onset 4/12/24). […]

• No harm, potential for more than minimal, patternF684Jun 18, 2026

  Based on observations, interviews, and record review, the facility failed to follow professional standards of practice for wound care for two residents (#28, #150) out of three sampled. Findings included:1. A review of Resident #28's medical record revealed an initial admission date of 6/12/26 with diagnoses to include: disruption of wound, unspecified, subsequent encounter; infection following a procedure, other surgical site, subsequent encounter; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere.A review of Resident #28's transfer form, dated 6/11/26, revealed a primary diagnosis of infected surgical wound.A review of Resident #28's hospital Discharge summary, dated [DATE], revealed an admission of 6/5/26 and discharge of 6/12/26. […]

• No harm, potential for more than minimal, patternF881Jun 18, 2026

  Based on review of infection surveillance data and interviews the facility failed to implement an effective antibiotic stewardship program related to unknown antibiotic utilization rates, antibiotic use without gathering infection criteria information, and improperly documenting unobtained culture results.Findings included: Review of the facility surveillance data showed the following documentation:March 2026 showed a one resident was ordered the antibiotic Levaquin without symptoms, no onset date, did not reveal a culture was obtained, no listed results and or sensitivity was confirmed. […]