Orlando Health And Rehabilitation Center

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

after a few seconds resident #6 let it drop to the floor. Resident #6 threw brief he was holding onto the nurses station.*On 10/05/25 at 3:52 PM, RN F on the phone while LPN B placed his hands on resident #6's shoulders. CNA L stood by resident #6 and LPN B. *On 10/05/25 at 3:55 PM, resident #6 was assisted to wheelchair by CNA L and LPN B. On 10/05/25 at 3:55 PM, RN M arrived at the unit. A few seconds later, RN H (weekend supervisor) and the Manager on Duty (MOD) arrived at the unit.*On 10/05/25 at 3:56 PM, RN F on the phone. Resident #6 taken wheeled to his room.*On 10/05/25 at 3:56 PM, LPN B entered room with dressing supplies; MOD also entered resident's room. Blood observed on the floor by nurses station.*On 10/05/25 at 3:58 PM, RN G (weekend supervisor) arrived. *On 10/05/25 at 4:05 PM, EMS (paramedics) arrived in the unit.*On 10/05/25 at 4:10 PM, resident #6 was wheeled out of his room, transferred to stretcher by EMS, dressing noted on his right hand and on his left hand extending to the forearm. A few minutes later, resident #6 left the unit with EMS. Review of the job description for the Certified Nursing Assistant (CNA) dated 7/1/19 showed the CNA was responsible for assisting residents with direct care under the supervision and guidance of licensed nurses (RN or LPN). The Essential Duties and Responsibilities included to report all observed or reported incidents of potential abuse, neglect or accidents immediately to their direct supervisor, manage combative residents while maintaining self-esteem and avoid injury to self and residents., respect the rights of each resident according to the Resident [NAME] of Rights, foster and support a culture of compliance and did not engage in abuse or neglect. Review of the job description for the Licensed Practical Nurse (LPN) not dated showed the LPN reported to Unit Manager (RN). The Essential Duties and Responsibilities included to supervise CNA staff, monitor all aspects of residents care, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed LPN had the authority to suspend individuals from work for rule violations. Review of the job description for the Registered Nurse (RN) not dated showed the RN reported to the Unit Manager (RN/DON). The Essential Duties and Responsibilities included to monitor all aspects of residents care, observe the residents and surroundings; identify changes in resident's behavior or conditions, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed the RN supervised LPNs and CNAs, enforced facility policies with authority to issue Disciplinary Action Reports as needed and the authority to suspend individuals from work for rule violations. Review of the Facility assessment dated [DATE REDACTED] revealed over 30% of residents had cognitive disabilities, including dementia. The form showed 47% residents had psychiatric disorders, and 7% exhibited aggressive behaviors. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orlando Health and Rehabilitation Center

830 West 29th Street Orlando, FL 32805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

statement of her phone conversation with CNA D which read, While speaking with [CNA D's name] I asked her what did she do when she saw the CNA holding the door She stated she told the nurse the CNA needed help and he (the nurse) told me, That is why the patient is on one to one. She also stated that the nurse [LPN B's name] told her to close the door of the resident (1106) because he was making too much noise and she then went into the room with the resident and closed the door. Review of the facility's security system did not show CNA A frightened or resident #6 running or punching the plexiglass partition by the nurses station. The video showed LPN B and CNA C saw CNA A holding resident #6's door closed with resident #6 inside his room, while he was trying to open it and get out. LPN E and RN F were sitting at the nurses station, across resident #6's room, and did not respond or intervene until a visitor alerted them to look at the resident. Review of resident #6's Observation Sheet dated 10/05/25 showed CNAs assigned for 1:1 observation were required to initial and document resident behaviors using codes every 15 minutes.

CNA A initialed the form at 3:45 and 4:00 PM and used codes 4 (aggressive toward residents) and 12 (combative). CNA A documented hospital from 4:15 to 7:45 PM. She initialed and documented codes 1 (in room lying in bed) and 2 (calm) from 8:00 to 10:45 PM. Review of the Immediate Nursing Home Federal Report submitted by Risk Manager (RM) O to AHCA on 10/06/25 at 3:02 PM revealed an allegation of physical abuse for resident #6. The report showed the incident occurred on 10/05/25 at 3:46 PM and the ENHA, EDON and RM became aware of the incident on 10/06/25 at 11:33 AM while performing a camera

review of the incident. The report read, As I was reviewing, I saw CNA [CNA A's name] holding the door to 1101B closed, I saw the door close on resident's fingers and when he came out of the room, he was bleeding holding a towel. He then walked to the nurse's station and was holding onto the plexiglass to maintain his balance and it came loose. The report mentioned resident #6 sustained no fractures of his hand or fingers but had scratches on his right four fingers from the door and scratches on his forearms from

the plexiglass. Review of CNA A's timecard revealed she worked on Sunday 10/05/25 until 11:34 PM. She returned to work on Monday 10/06/25 from 6:57 AM until 1:00 PM. Review of her assignment showed she cared for 10 residents until approximately 11:15 AM when the video footage was reviewed by management and she was removed from the unit. On 10/15/25 at 12:44 PM, the Medical Director stated he questioned who CNA A was and the kind of training she received. He stated he learned she had received required education, so training was not an issue. He mentioned the culture of not speaking up was one of the missing pieces in this incident as none of the staff working in the secured unit that day reported anything.

He stated they learned what happened through the cameras. Review of the job descriptions for CNA, LPN, and RN staff revealed each was required to report potential abuse immediately to their supervisor. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents.

Event ID:

Facility ID:

If continuation sheet