Inspection·May 2, 2024

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 neglect to the State Agency, (#1) and failed to report timely an allegation of neglect, (#3), for 2 of 2 residents reviewed for abuse, of a total sample of 7 residents. Findings: 1. Review of resident #1's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. She had diagnoses of dementia, fracture of neck of left femur, wedge compression fracture of the first lumbar vertebra, unsteadiness in her feet, and aftercare joint replacement surgery. Review of resident #1's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 2/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated she was cognitively impaired. The MDS assessment noted no rejection of evaluation or care necessary to obtain goals for her health and well-being. The MDS showed resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sitting on side of bed. She required partial/moderate assistance for chair/bed-to-chair transfer and toilet transfer. Review of the Agency for Health Care Administration (AHCA) Nursing Home Adverse Incident Report submitted on 12/01/23 revealed the following information: resident #1 was observed sitting on the floor in the dining area on 11/18/23 at approximately 5:30 PM and was assisted up by two Certified Nursing Assistants (CNAs). The report noted the assigned nurse was close by and witnessed staff assist the resident. The CNAs and the nurse acknowledged the event as the resident's common behavior with no follow up documentation or assessment done by the assigned nurse. At approximately 9:00 PM on the same day, resident #1's assigned CNA went to check on her and found her lying on her left side on the floor in her room. The report indicated the nurse was notified and resident #1 was assisted back to bed by two CNAs. The nurse and CNAs didn't think the resident fell but purposely laid on the floor, and viewed the incident as the resident's known behavior. No follow-up documentation was found in the resident's medical record. Incidents were not reported during the change of shift at 11:00 PM to the following shift. At approximately 4:00 AM on 11/19/23 during care, resident #1, Was making sounds like pain, but the CNA was unsure because resident #1 had similar known behaviors when she wanted to be left alone. On 11/19/23 at approximately 12:00 PM, the CNA notified the nurse resident #1 was crying out when she attempted to assist her with care. The nurse evaluated the resident and observed a yellowish discoloration to her left hip. She noted resident #1 had pain and notified the physician. An x-ray of the left knee, hip and femur were ordered, and the results revealed she suffered a fracture of the left femur. The resident was transferred to the hospital and underwent left hip (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: 106130 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 106130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health Center for Rehabilitation 1300 Hempel Avenue Ocoee, FL 34761 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)