MAITLAND, FL - State health inspectors documented multiple systemic failures at The Rehabilitation Center of Winter Park during an August 2024 inspection, including inaccurate resident assessments, incomplete care planning, delayed wound treatment, and improper medication administration procedures.
Critical Assessment Inaccuracies Compromise Care Planning
Surveyors identified significant errors in how the facility assessed residents' functional abilities, which directly impacted the level of care provided. The most concerning case involved a resident with severe cognitive impairment who required total assistance with eating, yet facility assessments incorrectly documented her as needing only partial assistance.
Resident #42, who had been readmitted with dysphagia, aphasia, stroke complications, and hand contractures, was documented on two consecutive quarterly assessments as requiring "partial/moderate assistance" for eating. However, the facility's own daily documentation told a different story. Certified Nursing Assistants recorded that this resident was actually dependent on staff for eating 16 out of 19 days during one assessment period, and six out of seven days during another period. The resident's care plan also specified she required "extensive staff assistance from one staff for participation to eat."
The Minimum Data Set (MDS) assessment serves as the foundation for determining appropriate care levels and staffing needs. According to the Resident Assessment Instrument guidelines, "partial/moderate assistance" means the helper does less than half the effort, while "dependent" means the helper does all of the effort or two or more helpers are required. This distinction is medically significant because residents who cannot feed themselves face substantially higher risks of malnutrition, aspiration, and weight loss if staff assistance is not properly allocated.
When the MDS Lead was interviewed, she acknowledged the assessments were incorrect and stated "any MDS coded incorrectly would require revision." She confirmed that accuracy of the MDS assessment was important so staff could take proper care of the resident. The facility's own policy emphasized that assessments must be conducted by individuals with knowledge to complete an accurate assessment and must reflect the resident's actual status and needs.
The implications of such assessment errors extend beyond documentation. When a resident's functional status is incorrectly recorded as more independent than reality, it can result in inadequate staffing assignments, insufficient supervision during meals, and increased risk of adverse outcomes. For a resident with dysphagia who cannot feed herself, the consequences could include choking, aspiration pneumonia, dehydration, or malnutrition.
Screening Failures Leave Vulnerable Residents Without Specialized Services
The facility failed to properly complete and update Preadmission Screening and Resident Review (PASARR) evaluations for multiple residents with serious mental health conditions. These screenings are federally mandated to determine whether residents with mental illness or intellectual disabilities require specialized services or alternative placement.
Resident #90, who had documented diagnoses of bipolar disorder, anxiety disorder, major depressive disorder, and substance abuse, had a PASARR completed in June 2023 that only listed bipolar disorder and substance abuse. When anxiety disorder and major depressive disorder were diagnosed just three days later, the facility never submitted an updated screening despite these being new mental health diagnoses.
The Social Service Director acknowledged during the inspection that a new Level I PASARR should have been submitted with the new diagnoses listed. The Director of Nursing confirmed the omission but stated she "did not know why it was missed." This resident's care plan indicated she was at risk for mood alterations and emotional outbursts, and she was receiving multiple psychiatric medications, underscoring the clinical significance of these conditions.
Even more concerning, Resident #100 required a Level II PASARR evaluation based on her Level I screening results, which indicated serious mental illness requiring specialized assessment. Despite this clear trigger for additional evaluation, the facility could not locate any evidence that the required Level II screening had ever been submitted. This resident had psychosis and major depressive disorder with severely impaired cognitive skills, yet the comprehensive evaluation necessary to determine her specialized service needs was never completed prior to or after admission.
PASARR screenings serve a critical protective function. They ensure that nursing facilities are appropriate placements for individuals with mental illness or intellectual disabilities, and they identify needs for specialized psychiatric or developmental services. Without proper screening, residents may not receive necessary mental health interventions, therapy, or psychiatric consultation, potentially leading to behavioral crises, medication mismanagement, or inappropriate placement in a setting unable to meet their complex needs.
The Social Service Director revealed she had initiated a PASARR audit in July 2024 to identify and correct deficient screenings throughout the facility, but went on medical leave before completing the corrective process. The Regional Nurse Consultant acknowledged awareness of the delays and admitted the Performance Improvement Plan for PASARRs was "ineffective because there were no target dates for completion of the tasks identified in the plan and delegation of tasks should have been done" during the Social Service Director's absence.
Delayed Wound Treatment Raises Quality Concerns
Inspectors documented a three-day delay between the discovery of a serious pressure ulcer and the initiation of ordered treatment, exposing the resident to unnecessary risk of infection and delayed healing.
On August 23, 2024, staff discovered an open area on Resident #42's left buttocks during routine skin observation. The facility's wound care physician evaluated the injury the same day and documented a sacral pressure ulcer measuring 6 x 3 x 0.3 centimeters with exposed necrotic fat tissue and serous drainage. The physician immediately provided specific treatment orders: cleanse with normal saline, apply Xeroform dressing, and cover with border dressing daily. Recommendations also included placement on a low-air-loss mattress, heel elevation, and pressure ulcer precautions.
Despite these clear and immediate orders, treatment did not commence until August 27, 2024—three days later. The facility's Treatment Administration Record confirmed wound care per physician orders began on that date, not when ordered. Additionally, the care plan addressing the resident's wound was not initiated until August 27, despite the pressure ulcer being identified and assessed on August 23.
Pressure ulcers require prompt, consistent treatment to prevent complications. Even brief delays in appropriate wound care can result in wound progression to deeper tissue layers, increased pain, higher infection risk, and prolonged healing time. For this resident, who already had severe cognitive impairment and multiple comorbidities including dysphagia and malnutrition, the delay represented a failure to provide timely medical intervention.
The unit manager acknowledged during the interview that she had seen the resident with the wound care physician on August 23 and knew the physician had performed debridement and applied initial dressing. However, she explained the physician had left the consultation note "somewhere on the nurses' station desk" rather than ensuring it was immediately processed. When asked directly, the unit manager confirmed "it was fair to say resident #42 had not received wound care for a few days" and validated "the physician orders were not followed."
The facility's own Skin Integrity policy, established in July 2023, stated the objective was "to decrease the prevalence and incidence of residents who developed pressure injuries and provide a guideline for optimal care to promote healing." The three-day gap between physician orders and treatment initiation represented a fundamental failure to meet this stated objective.
Tube Feeding Errors Risk Nutritional Deficiency
Nursing staff administered tube feeding to a resident at an incorrect rate for an extended period and failed to follow the prescribed feeding schedule, potentially compromising the resident's nutritional status and wound healing.
Resident #48 received nutrition through a gastrostomy tube due to dysphagia and had physician orders for continuous feeding at 75 milliliters per hour for 20 hours daily, with a four-hour break from 10:00 AM to 2:00 PM. On August 27, 2024, inspectors observed the feeding pump running at only 60 milliliters per hour—20 percent below the ordered rate. The error persisted through the following day when inspectors returned and found the pump still running at the incorrect rate.
When questioned, the Licensed Practical Nurse stated she "turned on the machine and that was the rate that was preset." She acknowledged she "did not verify the rate" against the physician's order. Another LPN explained she did not always compare the pump rate with physician orders because she "knew the resident's orders very well"—yet the resident was receiving an incorrect rate.
Beyond the rate error, staff also failed to maintain the prescribed feeding schedule. On August 27 at 4:40 PM, the feeding had been stopped at 11:30 AM (90 minutes late) and staff planned to restart it at 4:20 PM—more than two hours beyond the scheduled 2:00 PM restart time. This pattern of delays meant the resident was not receiving nutrition for extended periods beyond what was medically planned.
The clinical consequences of these errors are significant. Running tube feeding at 60 ml/hr instead of 75 ml/hr for 20 hours daily results in a deficit of 300 milliliters of formula per day. Over time, this represents hundreds of calories lost daily. The facility's Registered Dietitian explained that receiving an incorrect rate "for a prolonged period could cause unintentional weight loss, a calorie deficit, and poor wound healing." For Resident #48, who had diagnoses of moderate protein-calorie malnutrition, anemia, diabetes, and a stage 3 pressure ulcer, adequate nutrition was essential for healing and preventing further decline.
The facility's Enteral Feeding policy clearly stated the licensed nurse was responsible to "assure administration of nutritional products per physician's orders" and the purpose was "to ensure the safe and effective administration of enteral formulas." The Director of Nursing confirmed the expectation was for nurses to follow physician orders when administering tube feedings and that all nurses received competencies on tube feeding when hired.
Additional Issues Identified
Incomplete Care Planning: The facility failed to develop a comprehensive care plan for a diabetic resident receiving insulin injections until five days after her admission assessment was completed, despite facility policy requiring care plans to be developed based on assessment results.
Medication Administration Errors: Nurses administered Diclofenac topical gel without measuring the dose as required by manufacturer specifications, instead "squeezing some into a plastic medication cup." This medication requires precise dosing using a measurement card, particularly for patients with kidney disease who face increased risk of side effects. The resident receiving this medication had end-stage renal disease and was on dialysis, making accurate dosing especially critical.
Quality Improvement Deficiencies: The facility's Quality Assurance and Performance Improvement program failed to ensure that prior corrective measures were sustained, as evidenced by the recurring systemic issues documented during the inspection.
The August 30, 2024 inspection revealed multiple interconnected failures in assessment accuracy, care planning, treatment implementation, and medication administration. These deficiencies collectively indicate systemic weaknesses in clinical oversight, staff training, and quality monitoring processes at The Rehabilitation Center of Winter Park.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rehabilitation Center of Winter Park, The from 2024-08-30 including all violations, facility responses, and corrective action plans.
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