Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regents Park Of Winter Park during CMS and state inspections, most recent first.
A facility failed to protect residents from neglect, resulting in a fall with major injury for a resident who required assistance from two staff members for transfers using a full body mechanical lift. A CNA attempted the transfer single-handedly, leading to a fall and subsequent injuries. In another incident, a CNA neglected to review the care plan for a resident requiring a full body lift and attempted an inappropriate transfer, placing the resident at risk. These failures in care and service provision for mechanical lift transfers resulted in serious injury and risk for residents.
The facility failed to prevent a fall from a mechanical lift for a resident who required assistance from two staff members, resulting in a fracture and fear of using the lift. Another resident was at risk due to the use of an inappropriate lift type, as the CNA did not review the care plan. These incidents demonstrated a lack of adherence to care plans and proper equipment use, placing residents at risk for injury.
The facility failed to ensure CNAs demonstrated appropriate competencies for mechanical lift transfers, leading to incidents involving two residents. One resident fell during a transfer when only one CNA was present, contrary to the care plan requiring two staff. Another resident was nearly transferred using an incorrect lift method due to a CNA's failure to verify transfer instructions. The facility lacked proper validation and oversight of CNA competencies.
A resident with multiple health conditions experienced a delay in notification of a left femur fracture due to a failure by RN G to check x-ray results during his shift. The fracture was identified in the evening, but the physician was not informed until the next morning, delaying hospital transfer. The facility's policy requires immediate notification of significant changes, which was not followed.
A resident with severe cognitive impairment and multiple health issues expressed a preference for showers, documented in her medical records. However, she received mostly bed baths over a 67-day period. Interviews with the resident, her daughter, and facility staff confirmed the failure to honor her bathing preferences, as documented in the CNA Kardex and acknowledged by the DON.
A resident with a PICC line did not receive appropriate care and monitoring for IV therapy due to missing physician orders and oversight in the facility's check system. The resident's medical record lacked documentation for the insertion, monitoring, and flushing of the PICC line, and the baseline care plan did not address the IV therapy site. The facility's policies required regular checks and flushing of IV sites, but these were not followed, leading to insufficient care for the resident.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a facility due to inadequate supervision and monitoring. The resident, who had his electronic wander bracelet removed after being deemed not at risk, managed to exit through the front lobby door without staff noticing. Despite an alarm sounding, staff failed to investigate or communicate effectively, resulting in the resident being found outside the facility, highlighting lapses in supervision and record-keeping.
Neglect in Mechanical Lift Transfers Leads to Resident Injury
Penalty
Summary
The facility failed to protect residents from neglect, resulting in a fall with major injury for one resident and a near-miss incident for another. Resident #3, a vulnerable and physically impaired individual, required assistance from two staff members for transfers using a full body mechanical lift. However, on 11/22/24, a CNA attempted to transfer the resident single-handedly, leading to a fall when one of the sling's loops detached from the lift. The resident suffered blunt head trauma and a sacral fracture, and later developed a left hip fracture, which significantly impacted her quality of life. In another incident, the facility failed to ensure staff accessed and implemented the care plan for resident #2, who required a full body mechanical lift for transfers. A CNA neglected to review the care plan and attempted to transfer the resident using a sit-to-stand lift, which was inappropriate given the resident's weakness and poor balance. Although the transfer was averted due to a dead battery in the lift, the CNA's actions placed the resident at high risk for an adverse outcome. These failures in providing appropriate care and services for mechanical lift transfers not only resulted in a serious injury for resident #3 but also placed resident #2 and other residents requiring mechanical lifts at risk for serious injury or death. The facility's neglect in following established care directives and ensuring staff compliance with safety protocols led to these deficiencies.
Removal Plan
- The evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service.
- The CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended.
- The Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility's Administrator, Director of Nursing, and Medical Director to review the initial incident.
- The Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans.
- The MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents.
- The MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified.
- The Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified.
- Current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.
- Current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet.
- An Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation.
- The Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers.
- Nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
- Nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started and additional steps the facility is taking to re-educate staff.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns.
Failure to Adhere to Care Plans and Use Appropriate Equipment
Penalty
Summary
The facility failed to prevent an avoidable fall from a full body mechanical lift for a vulnerable, physically impaired resident. The resident's care plan required assistance from two staff members for transfers with a full body mechanical lift, but a CNA attempted the task single-handedly. During the transfer, one of the sling's loops detached from the lift, causing the resident to fall to the floor, resulting in blunt head trauma and a fracture of the sacrum. The resident developed a fear of using the mechanical lift, which affected her quality of life by limiting her participation in usual activities. Another incident involved the facility's failure to ensure the use of the appropriate type of mechanical lift for a physically impaired resident. The resident's assigned CNA neglected to review the care plan or kardex and attempted to transfer him with a sit-to-stand lift instead of the required full body lift. The resident exhibited noticeable weakness and poor balance, placing him at high risk for an adverse outcome as he was unable to stand. This oversight demonstrated a lack of adherence to the resident's care plan, which required two staff members to perform transfers with a full body mechanical lift. These failures in adhering to care plans and using the appropriate equipment placed residents at risk for serious injury. The incidents highlighted the facility's inability to follow its policies and procedures, contributing to a fall and fracture for one resident and potential harm for another. The deficiencies were identified during a survey, and the facility was notified of the Immediate Jeopardy status due to these failures.
Removal Plan
- The evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service.
- The CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended.
- The Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing, and Medical Director to review the initial incident.
- The Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans.
- The MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents.
- The MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified.
- The Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified.
- Current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.
- Current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet.
- An Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation.
- The Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers.
- Nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
- Nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey and additional steps the facility is taking to re-educate staff.
- An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over Kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns.
Deficiency in CNA Competency for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) possessed and demonstrated the appropriate competencies and skills to meet the needs of residents requiring mechanical lift transfers. This deficiency was identified through the cases of two residents who were not transferred according to their care plans. Resident #3, a female with multiple sclerosis and other significant health issues, fell during a mechanical lift transfer when only one CNA was present, contrary to the care plan that required two staff members. The CNA involved admitted to performing the transfer alone, despite recent training that emphasized the need for two staff members for such transfers. In another incident, Resident #2, a male with a history of seizures and muscle atrophy, was nearly transferred using an incorrect lift method. The CNA involved did not verify the resident's transfer instructions in the kardex and attempted to use a sit-to-stand lift instead of the required full body mechanical lift. This misunderstanding occurred despite the CNA having access to the correct transfer instructions in the kardex, which she failed to review properly. The facility's management acknowledged that CNAs had access to both the detailed nursing care plan and the simplified kardex, but there was a lack of clarity and training on how to use these resources effectively. The Director of Nursing admitted that staff were not required to demonstrate their understanding of the care instructions, and there was no checklist to ensure CNAs followed all necessary steps during transfers. This lack of proper validation and oversight contributed to the incidents involving both residents.
Failure to Notify Physician and Representative of Resident's Fracture
Penalty
Summary
The facility failed to immediately notify the physician and resident representative of a change in condition regarding a fracture for a resident reviewed for falls. The resident, an elderly female with multiple health conditions including multiple sclerosis and bone cancer, was found to have a fracture at the upper end of her left femur following x-rays conducted on the evening of December 11th. However, the results were not communicated to the physician until the following morning, approximately 12 hours later, which delayed the resident's transfer to the hospital for evaluation. The delay in notification was attributed to the assigned nurse, RN G, who did not check the electronic medical record for the x-ray results during his 16-hour shift. The Director of Nursing discovered the oversight while reviewing test results and orders the next morning. The facility's policy requires immediate notification of the physician and resident representative in the event of a significant change in condition, which was not adhered to in this case. The Medical Director and Unit Manager confirmed the expectation for immediate notification of abnormal findings, which was not met, leading to the deficiency.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred bathing method, which was a shower on scheduled days. The resident, who was admitted with diagnoses including cellulitis, gangrene, dementia, and diabetes, expressed a preference for showers on Mondays and Thursdays during the evening. Despite this preference being documented in the resident's medical records and CNA Kardex, the resident received only five showers over a 67-day period, with the majority of bathing instances being bed baths instead. Interviews with the resident and her daughter confirmed that the resident had communicated her preference for showers, but the staff continued to provide bed baths. The Bristol Unit Manager and the Director of Nursing acknowledged the discrepancy between the resident's documented preferences and the care provided. The Director of Nursing confirmed that the resident's choices were not honored, as evidenced by the bathing task report and lack of proper documentation for refusals or deviations from the resident's preferences.
Failure in IV Therapy Management for Resident with PICC Line
Penalty
Summary
The facility failed to provide appropriate care and services for the monitoring and management of an intravenous (IV) therapy site for a resident with a PICC line. The resident, who was admitted with multiple diagnoses including a displaced closed fracture of the left femur and sepsis, had a PICC line inserted in her left arm. However, there were no physician orders documented for the insertion, monitoring, or flushing of the PICC line on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for several days following the insertion. Additionally, the resident's baseline care plan did not include any information regarding the PICC line or IV therapy site. The Unit Manager and Director of Nursing acknowledged that the resident did not receive the proper monitoring or sufficient care for IV therapy. The facility's policy and procedure for intravenous therapy required that IV sites be checked every four hours or as per facility protocol, and that nurses confirm the patency of the IV site per flushing protocols. Despite these requirements, the resident's PICC line was not properly monitored or flushed, and the necessary physician orders were not entered into the system by the admission nurse. The oversight was attributed to a failure in the check system for new physician orders, which was supposed to be reviewed by the clinical team daily.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. On the morning of 7/25/24, a resident with a history of exit-seeking behavior and severe cognitive impairment managed to leave the facility without staff knowledge. The resident was not discovered missing until staff found him outside the facility, approximately 0.2 miles away, near an assisted living facility. This incident highlighted a lapse in monitoring and supervision, particularly concerning the front lobby door, which allowed the resident to exit unnoticed. The resident, who had been admitted with diagnoses including encephalopathy, unspecified dementia, and heart failure, was previously identified as at risk for elopement. Despite this, his elopement risk was reassessed in May 2024, and it was determined that he was no longer at risk, leading to the removal of his electronic wander bracelet. However, staff continued to document the placement and function of the bracelet even after its removal, indicating a lack of accurate record-keeping and communication among staff regarding the resident's status. On the day of the incident, multiple staff members interacted with the resident but failed to maintain adequate supervision. The resident was last seen at the nurse's station before he went missing. An alarm was triggered at the front door, but the staff member who responded did not investigate further or notify others, allowing the resident to remain unsupervised outside the facility. This series of oversights and miscommunications among staff members contributed to the resident's elopement and placed him at risk for potential harm.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 169 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winter Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winter Park Care And Rehabilitation | 0.4 mi | ★★★★★ | 2 | 0 |
| Mayflower Healthcare Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Parkview Rehabilitation Center At Winter Park | 1.1 mi | ★★★★★ | 0 | 0 |
| Alwyn C Cashe State Veterans Nursing Home | 1.8 mi | ★★★★★ | 6 | 2 |
| Westminster Winter Park | 1.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Regents Park Of Winter Park.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.