Conway Lakes Health & Rehabilitation Center
CONWAY LAKES HEALTH & REHABILITATION CENTER in ORLANDO, FL — inspection on February 1, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the ,d+[DATE] State Agency's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form, dated [DATE], revealed resident #3 required a surrogate for decision making, was alert, but disoriented, could follow simple instructions and was at risk for falls.
Review of resident #3's medical record revealed an admission assessment was completed on [DATE] which documented she was alert and oriented to person, place, and situation with no cognitive deficits. An elopement risk assessment completed the same day noted she was not an elopement risk because she ambulated independently with a walker, did not exhibit wandering or exit seeking behaviors, and had no memory issues.
Review of PT and Occupational Therapy's (OT)'s evaluation and treatment plans dated [DATE] revealed resident #3 was able to ambulate up to 150 feet with a four-wheel walker and partial to moderate assistance.
The assessment indicated she required some help with her functional cognition, had impaired safety awareness, and was at risk of falls due to her history of syncope and orthostatic hypotension.
On [DATE] at 2:19 PM, Registered Nurse (RN) C stated she usually worked on the west wing on the overnight shift from 11:00 PM to 7:00 AM but covered other shifts as needed.
She recalled a previous incident when a female resident exited the facility through the east wing door and ended up across the street at a gas station. RN C said it happened during the overnight shift and the Night Supervisor had to drive in her personal vehicle to get the resident.
She remembered the east wing door alarm went off which prompted staff to do a head count of all the residents, but was unable to remember the name of the resident or exactly when it occurred.
On [DATE] at 10:04 AM, RN D said in a phone interview she had worked at the facility since 2023 but had recently resigned due to differences with administration.
She recalled that on [DATE] she worked the 7:00 AM to 3:00 PM shift on the west wing. RN D said she arrived at work that morning around 7:00 AM and was told a female resident from the west wing had exited the facility via the east wing door.
She said the resident walked across the street to a gas station down the road before the Night Supervisor found her there. RN D recalled resident #3 was confused but had not been wearing an electronic wander prevention bracelet when she eloped.
105754
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105754 B.
Wing 02/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812
Review of a written complaint made to the state agency on 1/13/25 by an anonymous staff member revealed that a male resident eloped out the front door of the facility on 1/09/25, and the facility failed to supervise the resident or intervene when he had exhibited elopement behaviors.
The anonymous staff member stated previously a female resident eloped from the facility on the night shift and went all the way up the street.
The anonymous staff member indicated that the facility did not do education or drills after these elopements occurred and did not properly report the incidents.
On 1/27/25 at 2:19 PM, Registered Nurse (RN) C stated she recalled a female resident who eloped from the facility a few months prior, but she could not recall the resident's name.
She remembered the resident got out from the side door and, went to the end of the street.
She recounted that staff were alerted and attempted to search for the resident. RN C stated from the video that was seen of the resident after the elopement you could tell the resident had everything planned and she knew what she was doing. RN C stated she did not recall receiving any education or training after the incident, about elopements including preventing elopements or what to do if a resident was to elope.
Review of the facility's reportable and adverse incidents log for six months from August 2024 through January 2025 revealed the facility had no documented incidents or reports of neglect related to elopement.
On 1/28/25 at 3:35 PM, and at 5:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were asked if there were any possible elopements, and they denied there were any residents who had eloped or attempted to elope from the facility.
Later at 6:00 PM, the DON returned and stated that after speaking to the Assistant Director of Nursing (ADON) she now recalled a near miss with resident #3, but that she only went to the door and the alarms went off.
She explained the resident wanted to, take a stroll so the Night Supervisor walked outside with the resident.
The DON said the facility had cameras on the property, but they were antiquated, so video of the incident was not available to view.
The DON acknowledged that although she did not consider what happened to be an elopement, after the near miss she interviewed staff regarding the event, reviewed the incident during the Interdisciplinary Team (IDT) meeting, and had maintenance check all the doors.
She said they concluded the incident was not an elopement because the resident did not leave the property, and she had been supervised the whole time.
105754
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105754 B.
Wing 02/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812