Winter Park Care and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 17, 2024

  Based on record review, and interview, the facility neglected to provide appropriate care and services to prevent a fall with major injury for a vulnerable and physically impaired resident, during a transfer with a mechanical lift and failed to complete a thorough investigation after a fall with major injury for 1 of 6 residents sampled for falls, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. […]

• Immediate jeopardy, isolatedF689Feb 17, 2024

  Based on interview, and record review, the facility failed to prevent a fall with major injury for a vulnerable, physically, impaired resident, and failed to ensure the correct procedure was followed when using a mechanical lift to transfer residents for 1 of 6 residents sampled for falls, out of a total sample of 45 residents, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. […]

• Immediate jeopardy, isolatedF600Feb 17, 2023

  Based on observation, interview and record review, the facility neglected to implement policies and procedures and follow standards of practice related to care of a fracture with a brace for 1 of 6 residents reviewed for braces, (#1); and failed to provide the care and services to ensure the safety of a resident who was at risk for elopement for 1 of 6 residents reviewed for elopement, (#1), out of a total sample of 12 residents. These failures contributed to resident #1's hospitalization and elopement and placed him at risk for serious infection/injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. […]

• Immediate jeopardy, isolatedF684Feb 17, 2023

  Based on observation, interview and record review, the facility failed to obtain physician orders and implement nursing interventions to promote healing of a fracture and prevent skin injury related to use of a brace; and failed to arrange a required orthopedic consultation and update the plan of care with approaches for management of a brace for 1 of 6 residents reviewed for braces of a total sample of 12 residents, (#1). These failures contributed to resident #1's hospitalization and placed him at risk for decreased mobility and serious infection/injury/impairment/death. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. […]

• Immediate jeopardy, isolatedF689Feb 17, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for a physically and cognitively impaired vulnerable resident to prevent unsupervised exit from the facility through the front lobby doors for 1 of 6 residents reviewed for elopement, out of a total sample of 12 residents, (#1). This failure 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 likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. […]