MAITLAND, FL - Federal health inspectors cited The Rehabilitation Center of Winter Park for multiple care deficiencies during a routine inspection in August 2024, including a three-day delay in wound treatment for a vulnerable resident with a serious pressure ulcer.
Critical Wound Care Delays Put Resident at Risk
The most serious violation involved a resident who developed a stage 3 pressure ulcer on her sacrum that went untreated for three days after discovery. The resident, who had severe cognitive impairment and was dependent on staff for all care, was readmitted to the facility with multiple conditions including dysphagia, end-stage renal disease, and protein-calorie malnutrition.
On August 23, 2024, staff discovered an open area on the resident's buttocks during routine skin observations. A wound physician examined the ulcer the same day, finding a 6 x 3 x 0.3 centimeter sacral pressure ulcer with exposed fat tissue and ordered immediate treatment including specialized dressing changes and a low-air-loss mattress.
However, inspectors found that wound treatment did not begin until August 27, three full days after the physician's orders were written. During this critical period, the resident received no wound care despite having a serious injury that required immediate attention.
The facility's unit manager acknowledged the delay, explaining that the wound care physician had left the treatment orders somewhere on the nurses' station desk, and they were not discovered and implemented until three days later. "It was fair to say resident #42 had not received wound care for a few days," the manager admitted to inspectors.
Understanding Pressure Ulcer Risks and Treatment Needs
Stage 3 pressure ulcers represent full-thickness skin loss where subcutaneous fat becomes visible. These wounds typically develop when immobile residents experience prolonged pressure on bony areas like the sacrum. Without proper treatment, they can progress to deeper tissue damage and potentially life-threatening infections.
The delay in treatment violated standard medical protocols that require immediate intervention for pressure ulcers. Proper wound care includes regular cleaning, appropriate dressings, and pressure redistribution - all of which should begin immediately upon discovery. The three-day gap in treatment could have allowed bacterial growth, delayed healing, and potentially worsened the resident's condition.
The resident's medical history made prompt treatment even more critical. Her end-stage renal disease and malnutrition created additional healing challenges that required careful monitoring and immediate intervention when skin breakdown occurred.
Medication Safety Failures Endanger Dialysis Patient
Inspectors also found significant medication errors involving a resident on dialysis who was receiving Diclofenac gel, a topical anti-inflammatory medication. The facility failed to follow manufacturer dosing specifications for the medication, which posed particular risks for someone with kidney disease.
Licensed practical nurses were administering the medication by squeezing "about a fourth of a cup" into medication containers, rather than using the required dosing measurements. One nurse told inspectors: "I squeeze some into a plastic medication cup to take to her room," when asked about proper dosing procedures.
Diclofenac requires precise measurement using a dosing card, with specific amounts (typically 2 grams) for upper body applications. For patients with compromised kidney function, incorrect dosing can lead to serious complications including cardiovascular events and further kidney damage.
The facility's consultant pharmacist confirmed the risks, explaining that dialysis patients face "increased side effects of the medication because their kidneys were already compromised" when doses are not properly measured.
Tube Feeding Errors Compromise Nutrition
Additional violations involved improper tube feeding administration for a hospice resident with severe cognitive impairment. The resident required continuous nutrition through a gastrostomy tube due to swallowing difficulties and malnutrition.
Inspectors observed that nurses were running the feeding pump at 60 milliliters per hour instead of the physician-ordered rate of 75 milliliters per hour. They also found delays in feeding schedules, with one instance where the feeding was restarted more than two hours past the scheduled time.
These errors created nutritional deficits that could worsen the resident's already compromised health status. The facility's dietitian explained that incorrect feeding rates "could cause unintentional weight loss, a calorie deficit, and poor wound healing."
Assessment and Documentation Failures
The facility also failed to maintain accurate resident assessments, particularly regarding eating abilities and mental health screening requirements. Inspectors found discrepancies between documented care needs and actual observations, with some residents classified as needing only moderate assistance when they actually required total dependence for eating.
Additionally, the facility failed to complete required mental health screenings (PASARRs) for residents with psychiatric conditions, potentially missing opportunities for specialized mental health services and appropriate placement decisions.
Systemic Issues in Quality Oversight
The violations revealed broader systemic problems in the facility's quality assurance processes. Staff shortages, communication failures, and inadequate oversight contributed to multiple care breakdowns occurring simultaneously.
The wound care delay exemplified these systemic issues - critical physician orders were left unnoticed on a nurses' station desk for three days, suggesting inadequate communication protocols and order management systems.
Regulatory Standards and Expectations
Federal regulations require nursing homes to provide each resident with appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The violations at The Rehabilitation Center of Winter Park fell short of these standards in multiple areas.
Proper wound care protocols require immediate assessment, treatment initiation, and ongoing monitoring. Medication administration must follow precise dosing guidelines, particularly for residents with compromised organ function. Assessment accuracy ensures residents receive appropriate care levels and services.
Facility Response and Ongoing Monitoring
The inspection report requires the facility to submit corrective action plans addressing each violation. These plans must demonstrate how the facility will prevent similar incidents and ensure sustained compliance with federal standards.
The violations carry minimal harm classifications, indicating that while the deficiencies created potential for negative outcomes, they did not result in immediate serious injury or death. However, the cumulative effect of multiple care failures creates concerning patterns that require comprehensive remediation.
Federal and state health agencies will continue monitoring the facility's compliance through follow-up inspections and reviews of corrective actions. Families considering this facility should review the full inspection report and discuss these findings with administrators before making placement decisions.
The Rehabilitation Center of Winter Park must demonstrate sustained improvements in wound care protocols, medication administration, resident assessments, and overall quality oversight to maintain its certification for Medicare and Medicaid services.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.