Health inspection·October 29, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had an accurate medical record, of a total sample of 3 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility for respite care from home on 5/23/24, 6/07/24, 7/08/24, 8/23/24, and 9/16/24. The resident discharged home on [DATE], and most recently re-admitted on [DATE]. The resident's diagnoses included: cerebral arteriosclerosis, encounter for palliative care, holiday relief care, Alzheimer's Disease, vascular dementia with behavioral disturbance, gastrostomy (feeding tube), type 2 diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, and insomnia. The most recent comprehensive Minimum Data Set admission assessment with assessment reference date 10/01/24 noted resident #1 was unable to complete the Brief Interview for Mental Status and assessed by staff with severely impaired cognitive skills for daily decision making. No behavioral symptoms or rejections of evaluation or care was noted. The Functional Abilities assessment showed the resident used a wheelchair and was dependent on staff for mobility and to complete activities of daily living. No ulcers, wounds, or skin problems were noted on the assessment. The Comprehensive Care Plan included focus areas for fall with injury risks, impaired mobility, impaired self-care abilities, need for staff assistance, and impaired cognition. Review of the Agency for Health Care Administration (AHCA) Form 5000-3008 dated 9/23/24 revealed the skin care and body map section noted resident #1 did not have any areas of skin impairment or bruises. The nursing Admit/Readmit Screener evaluation completed by Licensed Practical Nurse (LPN) B on 9/24/24 at 1:35 PM, documented a complete skin assessment was conducted and revealed resident #1's skin integrity was normal with no areas of breakdown. A nurse's Progress Note completed by LPN B on 9/24/24 noted the resident #1's skin condition and read, . does have some spotty discoloration to bilateral legs and G tube (feeding tube) present to upper abdomen . On 10/29/24 at 10:39 AM, LPN B explained she completed skin checks for residents who were newly admitted or re-admitted to the facility. The LPN said nurses were required to document any bruises, injuries, wounds, or impairments on the electronic Admit/Readmit Screener form. The LPN recalled she was the only nurse who completed resident #1's re-admission evaluations on 9/24/24, and she did not (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105332 Printed: 05/28/2026 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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)