Provider Name: WINTER GARDEN REHABILITATION AND NURSING CENTER
Address: 12751 W COLONIAL DRIVE, WINTER GARDEN, FL 34787
Phone: (407) 877-6636
County: Orange (470)
Ownership Type: For profit - Corporation
Certified Beds: 120
Average Residents Per Day: 110. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: WINTER GARDEN REHAB, LLC
First Approved Date: December 9, 1985
Affiliated Entity: CITADEL CARE CENTERS (146)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 3 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.08129, LPN Staff Hours Per Day: 1.1213, RN Staff Hours Per Day: 0.2544, Licensed Staff Hours Per Day: 1.3757
Total Nurse Staff Hours Per Day, per resident: 3.45705
Weekend Nurse Staff Hours: 3.21245, Weekend RN Staff Hours: 0.1632
PT Staff Hours Per Day, per resident: 0.1114
Nurse Staff Turnover: 67.3, Nurse Turnover Note:
RN Turnover: 84.2, RN Turnover Note:
Admin Left Number: 3, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0002, Case Mix LPN Hours Per Day: 0.6957, Case Mix RN Hours Per Day: 0.3132
Adjusted Nurse Aide Hours Per Day, per resident: 2.11980, Adjusted LPN Hours Per Day: 1.1894, Adjusted RN Hours Per Day: 0.3061
Total Adjusted Nurse Hours Per Day, per resident: 3.62119
Adjusted Weekend Nurse Hours Per Day, per resident: 3.36497
Health Survey Dates and Scores: Cycle 1: 2023-06-02 (Score: 32), Cycle 2: 2021-11-04 (Score: 76), Cycle 3: 2020-01-30 (Score: 0)
Total Weighted Health Score: 41.333
Reported Incidents: 0, Substantiated Complaints: 4
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 9533.46, Payment Denials Number: 0, Total Penalties Number: 3
Location and GPS: 12751 W COLONIAL DRIVE,WINTER GARDEN,FL,34787 (28.5511, -81.571)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-08
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Post nurse staffing information every day.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-18
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-20
Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-20
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-13
Type: Health, Deficiency: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-13
Type: Health, Deficiency: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-13
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-04
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-04
Type: Health, Deficiency: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-04
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-04
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-14