Vivo Healthcare Lakeland

Inspectors wroteBased on observation, interview, and record review the facility did not ensure dental services were provided for one resident (#1) out of one resident sampled for timely dental care.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow sanitary infection control practices related to 1) proper storage and disposal of toileting items in two resident rooms (112 and 110), 2) proper nail length for three staff members (Staff P, Staff M, Staff Q), 3) and proper hand hygiene during meal service for one observed meal (6/23/25) during four days of survey. Findings Included: 1. During an observation on 06/23/2025 at 11:10 a.m., of room [ROOM NUMBER] B a plastic urinal was located opened on floor under the bed, with a wet area. During an observation on 06/23/2025 at 11:04 a.m., of room [ROOM NUMBER] bathroom an adult brief with yellow and brown markings was located in front of the toilet on the floor. (photographic evidence obtained) 2. [...]

Inspectors wrote2. During an observation from the hallway on 06/24/2025 at 9:46 a.m., Resident #146 was observed sitting up on the side of his bed with his legs hanging off, sleeping. Resident #146 was observed to have on a white T-shirt and a brief. Review of Resident #146's admission record revealed and admission date of 03/19/2025. Resident #146 was admitted to the facility with diagnosis to include Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Other Lack of Coordination, Major Depressive Disorder, Recurrent, Moderate, Mood Disorder Due To Known Physiological Condition with Mixed Features, Unspecified Dementia, Unspecified Severity, With Mood Disturbance. Review of Resident #146's Quarterly Minimum Data Set (MDS), dated [DATE] revealed, Section C-Cognitive Patterns had a Brief Interview Mental Status (BIMS) of 06 out of 15 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a homelike environment for four resident rooms (Rooms # 407, 422, 429) out of eight rooms sampled and failed to store equipment appropriately in one out of two shower rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure alleged resident to resident violations were reported to the governing agency in accordance with the State law for one (Resident #28) out of two residents sampled.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated for two residents (#69, #141) out of twelve residents sampled for PASRR.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet goals and address the resident's medical, physical, mental and psychosocial needs for three residents (#363, #28, and #49) out of thirty five residents sampled.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide Activities of Daily Living (ADL) for two residents (#154) related to removal of facial hair and (#367) related to showers out of four residents sampled for ADL. Findings Included: 1. During an interview on 06/23/25 at 11:10 a.m., Resident #154 was observed with long white strands of hair on her lip and chin. Resident #154 stated I wish they would help me pluck this hair off of my face. Review of Resident #154's admission record revealed an admission date of 05/21/2025. Resident #154 was admitted to the facility with diagnosis to include Need for Assistance with Personal Care, Neuromuscular Dysfunction of Bladder, Unspecified, Colostomy Status, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites and Multiple Sclerosis. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to provide nursing care and services related to 1) failure to schedule appointments for one (Resident #134); and 2) failure to administer medications in a timely manner for two (Resident #106 and Resident #90) out of 35 residents sampled. Findings Included: 1. During an interview on 06/25/2025 at 9:13 a.m., Resident #134 stated he had a catheter, but they recently removed it. He stated he had not seen a Urologist. During an interview on 06/25/2025 at 9:56 a.m., Resident #134's Family Member (FM) and emergency contact stated Resident #134 was referred to see a Urologist at the beginning of June, but has never been told if it was scheduled. The FM stated, the resident saw a Neurologist because he recently started having what she believed to be seizures when he sits up in bed. [...]

Inspectors wroteBased on interview and record review the facility did not ensure side effect monitoring was in place for one resident (#141) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication opportunities were observed, and two errors were identified for one resident (#133) out of six residents observed. These errors constituted a 7.14% medication error rate.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure food was properly stored and free of expired food(s) for residents in the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for two residents (#1 and #2) out of five residents identified by the facility at risk for elopement, to prevent elopement. Serious harm occurred on 4/19/25, when Resident #1 was allowed to walk away from the facility unnoticed, walk along high traffic streets for eight miles, and end up on an Interstate Highway where he was found by the [State Highway Patrol]. Resident #1 was taken to a higher level of care for evaluation and treatment of dehydration. On 3/25/25 Resident #2 exited the facility through an emergency exit door and was found 10 -15 feet from the door walking away from the facility. [...]

Inspectors wroteBased on interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an effective performance improvement plan to prevent the elopement of one resident (#1) out of five residents identified by the facility at risk for elopement.

Inspectors wroteCross Reference F921 Based on observations, interviews, and record review, the facility failed to provide supervision and failed to prevent accident hazards to prevent a fall with injury for one resident (#6) of 19 ambulatory residents in the memory care unit. The facility failed to replace a clean-out drain located in a high traffic area of the facility's memory care unit and failed to promptly and effectively address flooring issues, resulting in an unsafe walkway, where Resident #6 tripped and fell. On 1/20/2025, Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk independently and complete Activities of Daily Living (ADLs) at her prior functional level. The resident suffered a significant change due to a fractured right femoral head requiring a surgical intervention of a right hip arthroplasty. [...]

Inspectors wroteCross Reference F689 Based on observations, interviews and record reviews, the facility failed to provide a safe environment, free from flooring hazards for staff, the public, and 19 ambulatory residents in the facility's secure memory care unit. One (Resident #6) of the 19 ambulatory residents fell on 1/20/2025, sustained a fracture to the right femoral head (top of thigh bone), required a transfer to a higher level of care, and surgical intervention due to a floor repair that was not completed by the facility. The injuries to Resident #6 caused a significant decline in her ability to ambulate and complete activities of daily living (ADLs) at her prior functional level. [...]

Inspectors wroteBased on observation of videos posted on social media platforms without consent, review of resident records, policy and procedures review, and staff, family and resident interviews, the facility did not ensure personal privacy and confidentiality for ten of sixteen sampled residents (#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16). Findings Included: Review and observation of videos posted on social media platforms on 8/8/24, 10/2/24, 10/8/24, 12/2/24, and additional dates that could not be determined showed Resident #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 dancing or in the background of the videos, which also contained various staff members. These videos were recorded in various locations within the facility to include the secure memory care unit and hallways with room numbers where residents resided. [...]

Inspectors wroteBased on interview and policy review the facility failed to ensure an allegations of neglect were reported related to a fall with major injury due to the facility's failure to ensure a safe environment, free from flooring hazards for one resident (#6) of 19 ambulatory residents in the facility's memory care unit.

Inspectors wroteBased on interview and record review the facility failed to ensure documentation was accurate and complete for one (#4) of one resident related to the documentation of a change in condition resulting in cardio-pulmonary resuscitation (CPR) being administered.

Inspectors wroteBased on record review and interview, the facility failed to provide one (Resident #3) of one family-requested medical record in a timely manner.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure physician-ordered laboratory tests were completed for one (Resident #6) of three residents sampled for diagnostic laboratory testing.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for four (Residents #22, #67, #64, and#126); and 2.) ensure the accuracy of a PASRR Level I for six residents (#68, #130, #74, #98, #114, and #115) admitted with mental health diagnoses of fifty-four sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely meal service in one (400 unit) of four units for eleven (Residents #91, #102, #127, #116, #48, #37, #113, #33, #94, #29, and #14) of fifty four sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for three (Resident #114, #126, and #135.) of thirty-two sampled residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Planning problem areas to include 1. Advance Directives/Code Status, and 2. Utilization of Hospice services were reflective of the residents' current medical state and choices, for one (Resident #100) of fifty-four sampled residents.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to monitor for possible behaviors and side effects related to the use of psychotropic medications for three (Residents #22, #23, and #67) of eight residents reviewed for psychotropic medication use.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication administration error rate of less than five percent. A total of twenty-six medication administration opportunities were observed with six errors for two (Residents #120 and #19) of four residents sampled for medication administration, which resulted in a medication administration error rate of 23.08%.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure residents were provided with dietary meals and food items of their choices for two (Residents, #102, and #29) of fifty-four sampled residents .

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one of thirty-one sampled residents (#5), who required the use of foot boots/splints while in bed, were implemented per the care plan during four of four days observed (6/8/2021, 6/9/2021, 6/10/2021, and 6/11/2021).

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure one (#53) out of one resident sampled for pressure ulcers received wound care in a sanitary manner.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure accident hazards were addressed to prevent bruising to a resident's legs for 1 (Resident #30) out 6 residents sampled in hall 400.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure 1 (Resident #45) of 33 sampled residents had a urinary catheter and catheter tubing properly positioned for 3 of 4 observations made from 6/9/2021 to 6/11/2021.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to store medications properly in three (400-1, 300 hall, 100-3) out of seven medication carts and one (400 Hall) out of five medication storage rooms regarding unlocked medication carts, lack of refrigeration when needed, food items stored in the medication refrigerator, items not labeled with an open date and expired medications.

Inspectors wroteBased on observations, facility file review and staff interviews, the facility failed to ensure their pest control company was effective in keeping two of thirty resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) in hallway 400 free from live ants.