Winter Garden Rehabilitation and Nursing Center

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to include pressure and surgical wounds as part of Comprehensive Resident Centered Care Plans, for 2 of 3 residents reviewed for wound care, (#1 and #3), of a total sample of 4 residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement revised wound specialist physician's orders for a stage 3 pressure injury for 1 of 3 residents reviewed for pressure wounds, of a total sample of 4 residents, (#1). According to the Centers for Medicare & Medicaid Services (CMS), stage 3 pressure ulcers are described as full thickness tissue loss without bone, tendon, or muscle exposure. Stage 4 pressure ulcers include full thickness tissue loss with exposed bone, tendon, or muscle, (retrieved from cms.gov on [DATE]).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a high fall risk resident received timely post-fall assessment, pain management, and emergency medical intervention in accordance with professional standards of practice and the resident's comprehensive, person-centered care plan for one of four residents reviewed for falls, of a total sample of five residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents in a dignified and respectful manner for 1 of 6 residents reviewed for resident rights of a total sample of 12 residents, (#5).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment to protect residents, staff, and the public from potential burns to skin by not monitoring the hot water temperatures for water supplied to all resident rooms from 2 of 2 sets of hot water tanks; failed to maintain walls in a resident room in a sanitary manner, (#62); failed to repair the wall after a water leak under the sink, (#97); and failed to maintain the area around a wall unit air conditioner, leaving open space to the outside, (#97).

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 39 residents, (#93).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the care plan for activities of daily living (ADL) self-care deficit was revised to accurately reflect the interventions for toileting for 1 of 2 residents reviewed for bowel and bladder incontinence, of a total sample of 39 residents, (#89).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADLs) related grooming/personal hygiene for 1 out of 5 residents sampled for ADLs, of a total sample of 39 residents, (#88).

Inspectors wroteBased on observation, interview, and record review, the facility failed to address an alteration in a resident's skin integrity in a timely manner, for 1 of 4 residents reviewed for skin conditions, of a total sample of 39 sampled residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed regarding safe medication administration for 1 of 7 residents sampled for medication administration, of a total sample of 39 residents, (#51).

Inspectors wroteBased on interview, and record review, the facility failed to ensure an injury resulting in serious bodily harm was reported to the relevant Federal and State Agencies for 1 of 3 residents reviewed for falls, of a total of 10 residents, (#1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to present up-to-date staffing hours for residents and visitors in a complete and accurate format.

Inspectors wroteBased on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge form for 2 of 2 residents reviewed for hospitalization, of a total sample of 58 residents, (#82, #99).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive individualized care plan with interventions to address administration of Continuous Positive Airway Pressure (CPAP) for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice pertaining to continuous positive airway pressure (CPAP) for 1 of 3 residents (#90) reviewed for respiratory care, and failed to ensure oxygen concentrator was maintained in a clean manner for 2 of 3 residents (#28, #79) reviewed for respiratory care and failed to provide oxygen rate per physician order for 1 of 3 residents reviewed for respiratory care (#28) of a total of 58 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff received the necessary training for care of residents on continuous positive airway pressure (CPAP) therapy for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90).

Inspectors wroteBased on interview, and record review, the facility failed to ensure behavior monitoring was initiated and provided for 1 of 5 residents reviewed for Unnecessary Medication Review out of a total sample of 58 residents, (#434).

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all dietary staff were trained to operate a temporary dishwashing machine.

Inspectors wroteBased on observation interview and record review, the facility failed to develop a baseline plan of care for 2 of 2 residents reviewed in a total sample of 40 residents (#676 & 677).

Inspectors wroteBased on observation, interview and record review, the facility failed to dispense oxygen as ordered for 2 of 2 residents reviewed for respiratory care in a total sample of 40 residents (#677 & 35).