Rehabilitation Center of Orlando

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete and accurate personal funds/financial accounting statements were provided to 2 of 3 residents reviewed for Resident Rights, of a total sample of 3 residents, (#1, #2).

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure implementation of its Quality Assurance and Performance Improvement (QAPI) program to the extent that previously identified areas of concern were thoroughly monitored and performance was adequately tracked to ensure prior improvement measures were realized and sustained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to the use of personal protective equipment (PPE) outside of a resident's room, on one of two units, (West Wing).

Inspectors wroteBased on observation, and interview, the facility failed to provide residents a homelike dining environment for meals eaten in two of two dining rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 1 of 4 residents observed during the medication administration task, of a total sample of 38 residents, (#45). There were 3 errors in 28 opportunities for a medication error rate of 10.71%.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the snack/nourishment refrigerators on the nursing units had food items labeled and dated with open and use by dates and failed to ensure outdated foods were discarded to prevent the potential for foodborne illness, on two of two nursing units of the facility. This had the potential to affect all 110 residents at the facility.

Inspectors wroteBased on observation, and interview, the facility failed to dispose of garbage properly by keeping dumpster lids closed and the area surrounding the dumpster free of debris which had the potential to affect all 112 residents residing at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Review of the facility's QAPI Policy and Procedure dated 4/01/22 revealed, The facility will take actions aimed at performance improvement. It will measure the success of these actions and track performance to ensure that improvements are realized and sustained. The facility had deficiencies cited at F759 for medication error rate over five percent, and F867 for QAPI during the previous recertification survey conducted 1/07/24 through 1/11/24. During this survey, the facility was again found to be in noncompliance with F759, and F867. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure residents were treated with dignity by standing while assisting them to eat for 1 out of the 5 residents observed for dining assistance, of a total sample of 38 residents, (#34).

Inspectors wroteBased on interview, and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin for one of one resident reviewed for falls, of a total sample of 38 residents, (#3).

Inspectors wroteBased on interview, and record review, the facility failed to act promptly upon Resident Council group concerns with appropriate responses and rationale for facility decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse to State agencies as required for 1 of 2 residents reviewed for abuse, of a total sample of 8 residents, (#1).

Inspectors wroteBased 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.

Inspectors wroteBased on group interview and record review, the facility failed to ensure group grievances were acted upon promptly and provide a response and/or possible solution to group concerns for 6 months reviewed.

Inspectors wrote4. Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His diagnoses included fractured femur, orthopedic aftercare, and anemia. Review of resident #46's medical record revealed a nursing progress note dated 12/13/23 that noted he was hospitalized for a change of condition, Pain [uncontrolled] and the primary provider instructed to send to the hospital. The facility Transfer to Hospital form dated 12/13/23 indicated unplanned transfer due to recent fall on 12/8/23. Review of the hospital record dated 12/13/23 revealed his principal problem was fractured femur due to fall 5 days ago at SNF (Skilled Nurse Facility). The medical record did not contain Nursing Home Transfer and Discharge Notice form for this hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to prevent worsening of contractures for 1 of 1 residents reviewed for limited range of motion, out of a total sample of 57 residents, (#44).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient licensed nurses on the 7:00 AM to 7:00 PM shift to meet the needs and achieve the goals according to the plans of care for residents on 2 of 2 units, (West and East Wings).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure timely medication administration in accordance with accepted standards of practice for 1 of 5 residents reviewed for unnecessary medications, (#25); and failed to acquire medications within an appropriate timeframe for 1 of 19 residents with new admission status, (#218), out of a total sample of 57 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the menus/recipes were being followed and failed to demonstrate that a reasonable effort was made to ensure the menu/food met the needs of the residents. The facility also failed to ensure residents received foods based on the menus and meal tray tickets for 1 of 3 sampled residents, #53, in a total sample of 57 residents.

Inspectors wroteBased on observation, record review, and group interview, the facility failed to ensure meals were palatable, attractive, and served at an appetizing temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that accurately documented completion of physician-ordered wound treatments for 1 of 7 residents reviewed for pressure ulcers, (#44); oxygen administration for 2 of 2 residents reviewed for respiratory care, (#57 & #28); and provision of activities of daily living (ADL) care for 1 of 7 residents reviewed for ADLs, (#40), for 4 out of a total sample of 57 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to privacy during intimate encounters for 2 of 2 residents reviewed for privacy, out of a total sample of 57 residents, (#48 and #35).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide documented evidence that grievances were resolved promptly, and residents/family members were apprised of progress toward a resolution of grievances for 2 of 2 residents reviewed for grievances out of a total sample of 57 residents, (#54, 34).

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff-to-resident abuse to State agencies within the required 2-hour timeframe, and failed to report the incident to law enforcement for 1 of 4 residents reviewed for abuse, out of a total sample of 57 residents, (#13).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen therapy per physician orders for 2 of 2 residents reviewed for oxygen therapy of a total sample of 57 residents, (#28, and #57).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 1 of 4 residents sampled for medication administration, (#35). There were 2 medication errors in 26 opportunities for a medication error rate of 7.69%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent cross-contamination during wound care for 1 of 2 residents observed during wound care, (#44) to control and prevent infections for 2 out of a total sample of 57 residents.

Inspectors wroteBased on interview, and record review, the facility failed to retain daily nurse staffing data for 9 out of 27 weekends out of 18 months reviewed for staffing.

Inspectors wroteBased on interview and record review, the facility failed to conduct care plan meetings as scheduled, and failed to ensure the meetings were attended by the appropriate interdisciplinary team (IDT) members required to thoroughly review and/or revise the goals and care needs for 1 of 4 residents reviewed for care planning, out of a total sample of 57 residents, (#25).

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform physician-ordered wound treatments according to professional standards of practice to promote wound healing for 1 of 7 residents reviewed for pressure ulcers, out of a total sample of 57 residents, (#44).

Inspectors wroteBased on observation, interview, and review of facility documentation, the facility failed to ensure that surfaces of cooking equipment were kept free of accumulation of food residue as defined by facility policy concerning the cleaning of the oven.

Inspectors wroteBased 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. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 10/15/23 at 4:25 AM, the facility failed to prevent a moderate cognitively impaired resident from exiting the facility unsupervised. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care and services for oxygen therapy for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#10).

Inspectors wroteBased on observation, and interview, the facility failed to post the daily nurse staffing for licensed and unlicensed nursing staff directly responsible for nursing care per shift.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician laboratory orders for 1 of 5 residents reviewed for unnecessary medications of 44 sampled residents, (#147).