Inspection·October 11, 2023

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 ensure an injury resulting in serious bodily harm was reported to the relevant Federal and State Agencies for 1 of 3 residents reviewed for falls, of a total of 10 residents, (#1) Findings: Resident #1, a [AGE] year-old female was admitted to the facility originally on 1/12/21, with her most recent readmission on [DATE]. Her diagnoses included Parkinson's disease, urinary tract infection, acute respiratory failure with hypoxia, generalized muscle weakness, and abnormalities of gait and mobility, and history of falls. Review of the facility's incident log from June 2023 to current revealed the resident had a fall on 9/12/23. A nursing progress note dated 9/12/23 at 9:19 PM, indicated the resident was observed lying on her left side on the floor mat. Resident stated she was trying to get in wheelchair, since her son wants her to walk more. Review of the Change in Condition form dated 9/20/23 revealed the resident was transferred to an acute care hospital for evaluation per the resident's daughter's request. Although the resident had a fall on 9/12/23, a progress note dated 9/21/23 read, Call received from ER (Emergency Room) doctor, informed that resident is being admitted , T8 (Thoracic) fracture found, states it could have been a spontaneous break due to no record noted of recent fall, or trauma. On 10/10/23 at 2:45 PM, and 5:25 PM, the resident's fall and fracture were discussed with the Administrator and Director of Nursing (DON). The DON recalled that on 9/22/23, she was notified by the Advanced Registered Nurse Practitioner (ARNP), that resident #1 had a fracture that was probably due to Prednisone use. The Administrator stated the facility started an investigation and identified the resident had a fall on 9/12/23. She recalled they did an Adverse incident workup, and concluded the fracture was caused by the resident's fall on 9/12/23 with the resulting transfer to a higher level of care. The Administrator explained they did not submit a report to the Agency For Health Care Administration (AHCA) because the resident's care plan was followed. She noted that following the resident's plan of care was reason for not reporting the resident's fall with a fracture. The Administrator stated they did not have a policy for reporting but they followed the facility's (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 2 Event ID: 105518 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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)