Vivo Healthcare Winter Haven

Inspectors wroteBased on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) staffing data for the first quarter in the Fiscal Year 2025. Findings Included: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed there was no facility staffing data submitted for the period of October 1 to December 31 (FY Quarter 1 2025). During an interview on 04/10/2025 at 10:05 a.m., the Nursing Home Administrator (NHA) stated he had nothing to do with PBJ and was not aware they had triggered for not reporting PBJ data for Quarter 1. He stated they used a third party company who submitted their PBJ staffing hours. He stated he could pull the [NAME] report to view the hours but rarely looks at it. [...]

Inspectors wroteBased on interviews and records reviewed, the facility failed to developed and implemented action plans to correct identified quality deficiencies; measure the success of actions implemented and track performance to ensure improvements are realized and sustained, track medical errors and adverse events, analyze their causes, and implement preventive actions and mechanisms, conduct at least one Performance Improvement Plan (PIP) annually that focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis, and did not ensure the QAA Committee regularly reviews and analyzes data collected under the QAPI program and resulting from drug regimen reviews, and act on the data to make improvements. The Findings Included; Record review of the facility's policies and procedures titled Quality Assurance and Performance Improvement dated 9/2023 revealed: [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement an effective infection control program related to 1.) initiating contact precautions for one resident (#154) of one resident suspected and treated for a highly contagious condition, 2.) failed to clean shared equipment appropriately and store it in a sanitary manner, and 3.) failed to promote good hand hygiene by limiting the length of fingernails of direct care staff.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to establish an effective antibiotic stewardship program related to the antibiotic use protocols and monitoring the use of antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for 3 of 5 months reviewed and two (#19 and #69) of 52 total residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate Pre-admisson Screening and Resident Review (PASRR) screenings for eight residents (#2, # 67, #64, #83, #57, #26, #20, and #81) out of 52 residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the comprehensive person-centered care plans for three (#26, #38, and #7) of 52 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming assistance of shaving facial hair for four (#5, #14, #33, #46) of six residents sampled for activities of daily living (ADL).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective resident call system in four resident rooms (#204, #207, #403, and #609) of sixty four resident rooms in the facility

Inspectors wroteBased on observation interview and record review, the facility failed to honor the resident's right to a dignified existence and self-determination by failing to serve identifiable foods for two (#67 and #38) of two residents sampled for pureed diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders, assess the residents or develop care plans for two (#38 and #89) of two residents related to self-medicating for nebulizer treatments.

Inspectors wroteBased on record review and interview the facility failed to provide notification to the resident representative for one of six residents (Resident #106) sampled for accidents out of a total sample of 52 residents. Findings Included: Review of Resident #106's admission Record showed an admission date of 07/11/2024, discharge date of 07/16/2024 to an acute care hospital, and diagnoses to include urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, difficulty walking, and repeated falls. Resident #106 had three family members listed as emergency contacts on the admission Record. Review of the Change in Condition Evaluation dated 07/15/2024 at 2:43 a.m. showed Resident #106 fell on [DATE] at 2:20 a.m. Section 3. Resident/Representative Notification was blank. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to revise the care plans and related interventions accurately for one residents (#93) of fifty-two sampled residents related to indwelling urinary catheter.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess, document and/or treat a surgical wound for one (#96) of one resident sampled for skin conditions.

Inspectors wroteBased on observation staff interview and record review, the facility failed to ensure a contracture management program to include wearing of splints/orthotics was implemented for one (#7) of fifty - two sampled residents during three of three days observed (4/7/2025, 4/8/2025, and 4/9/2025).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure physician orders were in place for one (Resident #19) of two residents sampled for a Foley catheter.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to identify, implement, monitor, and modify interventions for one (Resident #33) out of 52 related to coughing during meals. Findings Included: During an observation on 04/07/2025 at 12:18 p.m., Resident #33 was observed sitting in the dining room with a plate of spaghetti, meatballs and garlic toast. Resident #33's eyes became watery and was observed coughing after taking a bite of food. Resident #33 continued to cough for a few seconds when staff approached Resident #33 raised her hands and removed the plate of spaghetti and toast. During an interview on 04/07/2025 at 1:19 p.m., Resident #33's Family Member (FM) stated that she had had an issue with the facility not assisting the resident with eating. She stated the resident had had issues with chewing her food and was supposed to be on a pureed diet. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure oxygen therapy was provided in accordance with professional standards of practice for two residents (#38 and #26) of four residents sampled and failed to ensure respiratory equipment was stored appropriately for two residents (#14 and #89) of four sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide behavioral health care services to one (#36) of three residents reviewed for mood and behaviors. Findings Included: During an observation on 04/07/2025 at 10:45 a.m., Resident #36 was heard from the nurse's station yelling out. During an observation on 04/08/2025 at 9:23 a.m., Resident #36 was observed hitting her leg and yelling out. Resident #36 was unable to answer any questions regarding her care. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure physician orders for medications with parameters were followed for two (#29 and #11) out of two residents reviewed.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain accurately documented medical records for vital signs, medication, and indwelling catheters for two (#98, #93) of 52 total sampled residents.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three Wings/Common areas (100, 400 and 600) of six Wings toured.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty-one medication administration opportunities were observed, and fourteen errors were identified for four residents (#40, #98, #93, and #53) of six residents observed. These errors constituted a 34.15% medication error rate.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain an effective pest control management system in nine rooms (100, 103, 108, 106, 207, 210, 303, 410, and 604) out of 52 rooms toured, and for one resident (#78) of one resident sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to reconcile, obtain, and provide medications as ordered, for two residents (#105 and #53) of five residents sampled for admissions/readmissions.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide an environment that was clean, sanitary, and well-maintained related to lack of housekeeping three halls (100, 400 and 600) of six halls affecting 12 resident rooms (604, 609, 101, 103, 102, 104, 400, 404, 406, 408, 411, 412 ), two storage areas (600-hall oxygen room, clean utility room) and broken handrails located in the hallway across from the therapy room and the dining room, and failed to ensure the ceiling was free and a black like substance and in good repair in one of one kitchen.

Inspectors wroteBased on observations, interviews, and record reviews the facility 1) failed to ensure staff appropriately donned Personal Protective Equipment (PPE) prior to entering isolation rooms for two residents (#74 and #561) out of two residents on Contact Precautions, and 2) failed to ensure staff were educated on Enhanced Barrier Precautions (EBP) on two hallways (400 and 100) out of six hallways in the facility, 3) failed to implement proper PPE during wound care for one resident (#105) out of one wound care observation, and 4) failed to ensure staff followed proper infection control practices related to nail care during medication administration.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to ensure an effective pest control system was in place in four halls (100, 200, 400 and 600) of six halls and one resident (#60) who resided in one of the affected halls.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one resident (#28) was assessed and determined to be clinically appropriate and safe to self-administer medications of two residents sampled for self-administration of medications.

Inspectors wroteBased on observations, interviews, and resident record review, the facility failed to ensure reasonable accommodations were made for one resident (#74) related to not providing an appropriate length mattress to ensure the resident's feet did not touch the footboard of six residents sampled.

Inspectors wroteBased on record review and interview the facility failed to transmit two comprehensive assessments for one resident (#96) out of two residents sampled for the task of Resident Assessments.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two residents (Resident #74 and #77) of fourteen sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for three residents (#10, #105, and #36) out of forty-seven residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses .

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure two residents (#93 and #461) of three residents sampled for skin impairments received wound care in accordance with professional standards related to changing dressings as ordered and documented and failed to assess and document skin conditions.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure two oxygen administration orders were clarified for one resident (#77) of two residents reviewed for respiratory care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure continuous communication with the dialysis center for one resident (#31) out of two residents reviewed for dialysis services.

Inspectors wroteBased on record review and interviews the facility failed to ensure staff administered medication with adequate indication for use and monitored the administration and effectiveness of this medication for one resident (#21) out of 28 sampled residents; and administered antihypertensive medication outside physician ordered parameters twelve out of thirteen administrations reviewed for one (#45) out of five residents observed during the task of medication administration.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and three errors were identified for two residents (#45 and #70) of five residents observed. These errors constituted a 10% medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring the range hood was free from dust.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a clean and homelike environment for 2 of 31 (#19, #27) sampled residents.

Inspectors wroteBased on interviews, record review, observation, and policy review the facility failed to ensure a grievance was acted upon for one resident (#46) of fifteen sampled residents.

Inspectors wroteBased on record review, interviews, and policy review the facility failed to ensure the necessary information was provided to the receiving facility during a transfer to the hospital for one resident (#16) of three residents sampled for a hospital transfer.

Inspectors wroteBased on record review and interview the facility failed to obtain documentation from a hospice provider to ensure coordination of services for 1 of 2 (#17) residents receiving hospice services.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide care and services consistent with professional standards of practice related to communication with the dialysis facility, as evidenced by a failure of monitoring resident status pre and post dialysis for one resident (#25) of four residents receiving dialysis.

Inspectors wroteBased on observation, record review and interview it was determined that the facility failed to provide Quality Assessment and Assurance (QAA) practice that demonstrated implementation of an effective action plan to correct the previously cited deficient practice at F584 related to providing a clean and sanitary environment for one resident (#17) out of three residents who received nutrition through enteral feeding.