The resident was walking in the hallway outside her room on January 20 when her foot caught on yellow and black striped tape that was peeling up from the floor. She fell, fracturing her right femoral head and requiring a hip replacement the next day.
The drain cover had been missing since December 18, when another resident with dementia had pulled it off. Maintenance placed a metal sheet over the opening and secured it with tape, marking the work order as "completed" nine days later without actually fixing the problem.
Staff witnessed the accident unfold. A nursing assistant coming down the hall with a breakfast tray saw the resident trying to detach herself from the loose tape when she lost her balance and fell. The resident's family member was walking with her at the time.
"The tape was coming up and Resident #6's foot got caught on it," the nursing assistant wrote in her incident report.
The resident, who had been walking independently up to 300 feet before the fall, suffered severe cognitive decline after the surgery. Her mental status assessment score dropped from 9 to 0, indicating progression from moderate to severe impairment. She became completely dependent for all activities of daily living and now uses a wheelchair.
Inspectors discovered the facility had known about multiple flooring hazards for months but failed to address them promptly. A licensed practical nurse had reported missing tiles in the same hallway on December 3. That work order remained marked "in progress" until February 26, nearly three months later.
The Director of Maintenance told inspectors he had tried to save the company money by researching a replacement drain cap himself instead of calling plumbers immediately. He used what he called "good tape" as a temporary fix and checked it daily, though his own monitoring log showed gaps of multiple days without inspection.
"I felt the location where Resident #6 fell was safe," the maintenance director said. He ordered a diamond grinding wheel to smooth the concrete patch left by plumbers but claimed it was backordered. Records showed he didn't place the order until January 27, a week after the resident's fall.
The unit manager described the concrete area as being in a high-traffic zone between the dining room, the nursing station, and the resident's room. She said residents with dementia frequently wandered the hallways and wouldn't recognize the striped tape as a warning.
"The metal and tape was a hazard," she told inspectors. "During the repair period, the area had become larger in size."
Inspectors found additional safety violations throughout the facility during their February visit. Twelve tiles were missing from another section of the memory care unit, creating an uneven walking surface that staff estimated had been in disrepair for six to eight months. The entrance ramp to another wing was missing ten carpet squares, leaving exposed concrete with a raised drain.
The nursing home administrator acknowledged the problems during the inspection tour. She confirmed that tiles were popping up where the facility had attempted repairs using old materials, creating hazards for residents with shuffling gaits.
"The tiles needed to be put down again and better," she said. "It was unacceptable to wait to repair the floors."
The facility's own fall prevention policy required maintaining "clear pathways" and environmental safety measures for all residents. The injured resident had a documented fall risk score of 9 before the accident and 17 afterward.
Federal inspectors determined the facility's failures created "immediate jeopardy" to resident health and safety. The violation affected not only the injured resident but placed 18 other ambulatory residents in the memory care unit at risk.
The resident's care plan, revised after the fall, now includes interventions to "keep environment/walkway free of trip hazards" and assistance from family to "declutter room for safety." She receives pain medication including Tylenol, lidocaine patches, and Tramadol.
The facility implemented emergency measures during the inspection, including assigning a dedicated hallway safety monitor 24 hours a day and educating 99 percent of staff on hazard reporting procedures. Corporate maintenance support was summoned to address the flooring issues.
Inspectors also cited the facility for failing to properly document that the resident received CPR during her medical emergency. The Director of Nursing confirmed that cardiopulmonary resuscitation was performed but acknowledged the clinical record failed to include this critical information.
The immediate jeopardy finding was removed on February 28 after the facility completed repairs and staff training. However, at the time of the inspection, some flooring issues remained unresolved more than a month after the resident's fall.
The Regional Director of Maintenance, who was not aware of the flooring problems, said safety issues should be handled within one to two weeks. The nursing home administrator stated her expectation was "an immediate fix for any hazard affecting residents."
The injured resident remains at the facility, now requiring total assistance for mobility and personal care tasks she had previously performed independently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vivo Healthcare Lakeland from 2025-02-28 including all violations, facility responses, and corrective action plans.