Winter Garden Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
told them he was testing out his acting skills because the CNA was late and he thought that would be funny.
The NHA stated she educated resident #5 and told him his behavior was inappropriate and disrespectful to other residents. She shared he thought other residents would find it funny and he was now embarrassed, so he did not want to return to his room because his roommate was in the dining room when the incident happened. She stated resident #5 was offered a room change which he accepted. The NHA stated she was unaware resident #5 thought he could not eat his meals in the dining room. The NHA denied making the decision to prohibit resident #5 to eat his meals in the dining room for 30 days and could not explain why resident #5, other residents, and staff would say that. She shared it was resident #5 who stated he would take a break from going to the dining room. On 9/25/25 at 5:34 PM, during a telephone interview, the former Director of Nursing (DON) explained she was not present when the incident occurred, but she returned to
the facility shortly after. She stated the kitchen corroborated nursing staff was not in the dining room when
the dinner trays were brought out but said they arrived within five minutes. She said the nurse who came to serve the residents did not know the process and started passing coffee instead of the trays, and resident #5 went ballistic. She stated he was placed in another room temporarily and she received physician orders for laboratory tests and a psychiatric evaluation. She stated the NHA came after she had left and added steps to keep everyone safe. She recalled having a Resident Council meeting the next morning which resident #5 attended. She indicated she explained the new plan they implemented to make the dining process smoother. She shared he was such a mild manner man and they were surprised by his behavior.
She indicated she felt once they resolved the dining room process, everything would be okay. She said not allowing him to return to the dining room for his meals for 30 days was extreme, but it was not her decision.
She stated he enjoyed doing eating in the dining room, and they informed resident #5 he could participate
in certain activities but could not eat his meals in the dining room or go on outings. Review of the minutes for an Emergency Resident Council Meeting held on 8/30/25 revealed 12 residents attended including the Resident Council President and resident #5. The form showed residents expressed concerns about the previous evening event and overall meal delivery. The DON shared their new plan to be implemented to ensure a smooth process in the dining room. The residents agreed with the plan. Review of the facility's Resident Rights policy and procedure revised on January 2024 read, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.
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WINTER GARDEN REHABILITATION AND NURSING CENTER in WINTER GARDEN, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINTER GARDEN, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINTER GARDEN REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.