Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, and record review, the facility failed to act promptly upon Resident Council group
concerns with appropriate responses and rationale for facility decisions.
Residents Affected - Some
Findings:
On 8/07/24 at 3:18 PM, the Resident Council President stated there were issues brought up in resident
council meetings for many months that were still unresolved. The first issue was a long response time to
call lights by staff. He stated staff often told the residents; they would be right back but then forgot to return.
He added staff would say, That's not my section, when asked to answer a call light or pass meal trays when
the assigned Certified Nursing Assistant (CNA) was busy. The Resident Council President explained there
were other ongoing issues such as late meals, cold food due to the plate warmer being broken for months,
and residents not being able to get ice. He explained the Resident Council had concerns about language
barrier issues with staff, and smoking issues. The Resident Council President stated the group was
concerned the Activities Director had at times invited staff to the resident council meetings without the
knowledge or invitation of the group and the group meeting location was not private enough. The Resident
Council President explained there were told by the facility Administration that their concerns were being
worked on but no details, progress updates, or results were provided. He stated he often wondered why the
Resident Council group met at all, because residents felt like they were ignored.
On 8/07/24 at 3:00 PM, the Activities Director stated she helped run the Resident Council and the Food
Committee meetings. She acknowledged sometimes she invited other facility staff to attend the Resident
Council meetings.
On 8/07/24 at 4:30 PM, Resident Council meeting minutes dated January 2024 to July 2024 which included
many unresolved issues. The 2/06/24 meeting minutes indicated the old business regarding medication
pass issues were, In process and still being worked on. Regarding the issue of call lights, the action plan on
these minutes stated call lights should be answered within 5 minutes, the head nurses would monitor call
lights, and all department heads could answer a call light and assist that resident. In addition, new concerns
about ice were raised. Call light response times concerns were brought up repeatedly at meetings on
3/05/24, 4/02/24, 5/07/24, 6/04/24 and 7/02/24. The feedback given was the resolution was, In progress.
Late meals delivery was brought up as an issue at meetings on 4/02/24, 5/07/24, 6/04/24 and 7/02/24 and
an issue of room checks not being conducted during night shifts was brought up on 5/07/24, 6/04/24, and
7/02/24. These items were still unresolved with their resolution noted in the meeting minutes also, In
progress.
On 8/08/24 at 2:15 PM, the Certified Dietary Manager (CDM) stated they were still having difficulty with late
delivery of meals. He confirmed the plate warmer had been broken for about a month. He
(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 5
Event ID:
105471
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
105471
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center of Orlando
9311 S Orange Blossom Trl
Orlando, FL 32837
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 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
stated the Director of Maintenance was ordering a part for it. The CDM stated the ice machine was not
broken but it did not produce a sufficient amount of ice. He said the repair company stated the ice machine
was working as it should. The CDM was not aware residents had complained about not having enough ice.
On 8/08/24 at 6:00 PM, the Administrator stated the facility investigated and addressed grievances from
residents as they arose. The Administrator stated a grievance regarding call light response time had an
action plan to audit the response times. Three audits were completed in February and March 2024 and the
Administrator stated call light response times were not deemed to be an issue any longer after this. The
Administrator acknowledged the call light complaints brought up at the Resident Council meetings from
February 2024 through July 2024. He also acknowledged the action plan which indicated the correction
was In progress. The Administrator explained call light issues would never be corrected. He stated he
probably should pay more attention to issues brought up by the Resident Council.
The facilities Resident's Rights policy dated April 1, 2022 states resident groups have the right to meet in a
private space with other staff and visitors only attending only at the group's invitation. It also states the
facility must consider the views and recommendations of the group and act promptly on the grievances and
recommendations of the group. It states the facility must be able to demonstrate its response and the
rationale for it. It was not evident this policy is being followed effectively.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105471
If continuation sheet
Page 2 of 5
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
105471
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center of Orlando
9311 S Orange Blossom Trl
Orlando, FL 32837
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 - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to report an allegation of verbal abuse to State agencies as
required for 1 of 2 residents reviewed for abuse, of a total sample of 8 residents, (#1).
Findings:
Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses
including encephalopathy (brain dysfunction), paraplegia (paralysis of lower body) and dementia. Her
medical record showed her daughter was her Power of Attorney (POA) and responsible party. Resident #1
was discharged from the facility on 6/30/24.
Review of the Minimum Data Set (MDS) Annual assessment with assessment reference date of 5/27/24
revealed resident #1 had unclear speech but sometimes understood and responded adequately to simple,
direct communication only. The assessment showed a Brief Interview for Mental Status (BIMS) was not
conducted because she was rarely or never understood. The MDS assessment showed resident #1 had no
behavioral symptoms and did not reject evaluation or care necessary to achieve her goals for health and
well-being. Resident #1 was totally dependent on staff for all activities of daily living. The assessment
revealed her preferred language was Creole and she needed an interpreter to communicate with a doctor
or health care staff.
Review of the care plan with a focus area of little community life involvement revised on 11/05/23 revealed
resident #1 was French Creole speaking and needed a translator. Another focus revised on 1/19/23 was
communication problem related to dementia and language barrier, Creole speaking.
Review of the Monthly Grievance Log from February to August 2024 showed resident #1's POA had filed 7
grievances. The June log included a grievance/concern dated 6/10/24 for customer service/nursing care
which was assigned to the Unit Manager on 6/11/24 and the resolution noted education of customer
service to Certified Nursing Assistants (CNAs). The Grievance Report on 6/10/24 read, [resident #1's
daughter name] called today 6/10/24 stating she came in yesterday, Sunday 6/09/24. Her mother told her
that either on Friday or Saturday a CNA was yelling and cursing at her mother in Creole. The CNA was
calling her a witch and said that is why your body is like that. The mother was very upset and crying, she
didn't even want to eat. [Resident #1's name] even told her to stop talking on her behalf because people are
now being mean.
Review of the facility abuse log since did not show any entries for resident #1 over the past 3 months,
including June 2024.
On 8/07/24 at 2:46 PM, the Social Services Director stated she was the Grievance Officer. She shared the
grievance process included reviewing the new grievances, assigning the grievance to the appropriate
department and ensuring they were resolved within five days. Later on 8/08/24 at 4:40 PM, the SSD
reviewed resident #1's grievance dated 6/10/24. The Social Services Director read the grievance out loud
as requested by the surveyor. When she finished reading the statement, she stated resident #1's BIMS was
zero, which indicated her cognition was severely impaired. She indicated the grievance form was completed
by her assistant, but she was also in the office when the call came in. The Social Services Director stated
she mentioned the grievance the next morning in their daily meetings with the Administrator and other
management, but she did not discuss the concerns thoroughly. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105471
If continuation sheet
Page 3 of 5
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
105471
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center of Orlando
9311 S Orange Blossom Trl
Orlando, FL 32837
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 - Few
explained the only thing discussed during those meetings was a new grievance was received for resident
#1 and which was given to the Unit Manager for follow up. When asked, the Social Services Director stated
she did not know who the abuse coordinator was. She did not consider this grievance an abuse allegation
because it was not that a CNA hit her. The SSD re-read the grievance and acknowledged it described
verbal abuse, but said this was one sided, because her mom doesn't talk. She added, In that instance, who
are we to believe? It is all one sided because her mom doesn't talk.
On 8/07/24 at 4:53 PM, the Administrator joined the interview with the Social Services Director and
indicated he was the abuse coordinator. He stated he was, a little confused when he read the grievance
dated 6/10/24. The Social Services Director interjected and said resident #1 did not talk. The Social
Services Director told the Administrator the grievance was about the daughter saying what allegedly
resident #1 told her. The Administrator read the grievance out loud. He stated he did not recall if he learned
about this grievance before. He explained abuse could be physical or verbal. He added, Sounds like that
could be a verbal abuse allegation that we would investigate. He explained they would have tried to identify
the CNA and suspend her/him and filed an immediate report for verbal abuse. He indicated the
investigation would include interviewing some of the surrounding residents in the CNA assignment or in the
same area and concluded submitting a 5-day report with their findings. He stated they took all abuse
allegations seriously and reported within the required time frames. Later on 8/08/24 at 5:39 PM, the
Administrator stated the Assistant Director of Nursing (ADON) had investigated it quickly and found out
there was no Creole speaking staff assigned, to resident #1 on the dates noted. He mentioned the best
course of action was to do a customer inservice with staff. When asked for the copy of the staff
assignments for that weekend and results of the quick investigation he said the ADON did not keep copies
or documentation of what she reviewed.
Review of the facility's policy and procedure titled Abuse: Florida, dated 4/01/22, revealed reports of abuse
were promptly and thoroughly investigated. The document included abuse allegations were to be reported
per Federal and State Law, immediately but not later than two hours after the allegation was made if it
resulted in serious body injury or not later than 24 hours if no serious body injury occurred. The document
indicated the facility was required to comply with external reporting requirements including the State
Agency and law enforcement.
Review of the facility's policy and procedure titled Grievance Program, dated 4/01/22, revealed concerns
related to alleged abuse would be handled according to state and federal guidelines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105471
If continuation sheet
Page 4 of 5
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
105471
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center of Orlando
9311 S Orange Blossom Trl
Orlando, FL 32837
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on interview and record review, the facility failed to ensure implementation of policies to the extent of
including thorough monitoring of previously identified areas of concern and adequately tracking
performance to ensure prior improvement measures were realized and sustained.
Findings:
Cross reference F565 and F609
Review of the facility's survey history revealed deficiencies related to Resident Council's grievances and
recommendations to improve residents' care had not been considered or acted upon and an allegation of
abuse was not reported were identified during the current survey ending on 8/08/24.
The facility had deficiencies at F565 and F609 for similar concerns with Resident Council and reporting of
abuse allegations from the last Recertification survey dated 1/11/24.
Review of the Plan of Correction (POC) which serves as the facility's allegation of compliance with the
citations, approved by the Quality Assurance and Performance Improvement (QAPI) committee on 2/15/24
included education to the Interdisciplinary team for understanding of the QAPI process. The POC
mentioned implementation of appropriate plans of action to prevent repeat deficiencies. The POC
mentioned identifying areas for continuous quality monitoring using tools to conduct quality reviews which
would be reviewed in QAPI for identification of areas that could potentially affect resident outcomes.
On 8/08/24 at 9:33 AM, the Administrator stated he was responsible for overseeing all areas in the facility.
He explained his main function was to manage the different departments and ensure compliance. He
shared his passion was for residents to be treated fairly and received the best quality of life they could get.
The Administrator stated when he took the position in January, he met with the Resident Council and had a
crowd of about 30 residents. He stated he informed them he would walk around the first few weeks, to see
what resident saw and address those issues, which he did. He stated they were currently working on quality
measures, and he stated he was surprised about the survey findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105471
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
FAQ · About this visit
Common questions about this visit
What happened during the August 8, 2024 survey of REHABILITATION CENTER OF ORLANDO?
This was a inspection survey of REHABILITATION CENTER OF ORLANDO on August 8, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at REHABILITATION CENTER OF ORLANDO on August 8, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.