Lakeland Nursing & Rehabilitation

F-F689 Residents Affected - Few 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 [DATE REDACTED], 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.

The facility's failure to maintain a safe walking environment caused serious injury and harm to Resident #6 and placed 18 additional ambulatory memory care residents, staff, and visitors at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25.

The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D.

Findings included:

A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of

an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall

on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created.

During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to

the facility on [DATE REDACTED], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to Level of Harm - Immediate include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with jeopardy to resident health or routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial safety hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation.

Residents Affected - Few A review of the Situation, Background, Appearance, and Review (SBAR) evaluation for Resident #6, dated 1/20/25, showed the resident tripped and fell in the hallway, complaining of lower back and right leg pain.

The evaluation revealed new pain in the right thigh, lower back and right leg with an intensity score of 9 of 10. The documentation revealed the resident was left in place due to pain on movement, and the primary physician placed an order to send the resident to the emergency room (ER) for evaluation on 1/20/25 at 8:40 a.m.

An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her Family Member (FM). The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall.

Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down

the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it.

A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed This is

a [AGE] year-old female with medical history of dementia, dyslipidemia, COPD [chronic obstructive pulmonary disease], nursing home resident, presented to hospital for [sic] facility after a fall. Patient was found on the ground and complaining of right hip pain, patient's baseline is confused, only be able to recognize her [FM], but nobody else, be able to eat by herself. When I saw the patient, her [FM] at bedside, provided all the history. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization.

A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness.

A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 A review of the hospital Physical Therapy (PT) evaluation dated 1/22/25 at 9:38 a.m., revealed the FM had reported a prior functioning of being able to mobilize with a walker. The PT assessment showed Level of Harm - Immediate Impairments/Limitations: Ambulation deficits, Bed mobility deficits, Cognitive deficits, Range of motion jeopardy to resident health or deficits, Safety awareness deficits, Transfer deficits, Transition deficits safety Barriers to Safe Discharge: Insight into deficits, Needs Assist for Mobility, Needs Assist for Transfer, Safety Residents Affected - Few awareness

Summary of Findings: Pt. [patient] very confused, unable to follow commands, dep[endent] for all mobility.

A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty. The record showed the resident was in pain whenever touched. The resident had a surgical wound on right thigh and staff recommended rehab unit for the resident.

During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell . The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall

on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls.

On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen.

The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch.

On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated

the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a Level of Harm - Immediate circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it jeopardy to resident health or and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a safety metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated Residents Affected - Few she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size.

A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research

a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit

the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself

before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area.

On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for

the safety of the residents.

On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a long time and estimated it to be approximately 6 to 8 months.

A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p. m. by the DOM with a status of Set to completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was Level of Harm - Immediate not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone jeopardy to resident health or was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff safety and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs. Residents Affected - Few

During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors.

Photographic evidence was obtained.

A review of the Maintenance Director's job description signed on 10/24/24 by the DOM revealed:

Position Purpose: Directs the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and to ensure the facility is maintained in a safe and comfortable manner.

The major duties and responsibilities included:

Plans, develops, organizes, implements, evaluates, and directs the Maintenance Department, its programs and activities.

Ensures the facility remains in compliance with all federal, state, and local regulations for life safety code compliance.

Reviews the department's policies, procedure manuals, job descriptions, etc., at least annually for revisions and makes recommendations to the Assistant Administrator/Administrator.

Prepares operating and staffing budgets for maintenance and monitors monthly.

Ensures maintenance staff are properly trained on safety policies and procedures as well as monitors compliance.

Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry, HVAC, and electrical work.

Purchases within budgetary responsibilities [sic] the general maintenance tools, supplies and equipment, safety equipment, and trains others in their appropriate use.

Ensures that services performed by outside vendors are properly completed/supervised in accordance with contracts/work orders .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Ensures facility's compliance with multiple OSHA standards .

Level of Harm - Immediate Develops and implements preventative maintenance tasks, document instructions and procedures for the jeopardy to resident health or preventative maintenance of facility and utility components and office equipment, as well as, mechanical, air safety conditioning, heating, and electrical systems, etc.

Residents Affected - Few Schedules department work hours (including vacation and holiday schedules), personnel, work assignments, etc., to expedite work .

Ensures the facility's compliance with the law and other regulatory terms such as safety and building codes .

Runs, operates, and assesses technical aspects of facility machinery, equipment, and buildings.

A review of the Job Description for the Administrator signed on 1/9/24 revealed:

Position Purpose: Leads, guides, and directs the operations of the health care facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.

The major duties and responsibilities included:

Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations.

Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body.

Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility .

Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc .

Evaluates work performance of department heads and maintains accountability across all departments in concert with Human Resources for expected performance outcomes in each respective department .

Knows and understands .Code of Federal Regulations, Appendix PP State Operations Manual .Life Safety Code regulations .and all other regulatory entities that may apply .

Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open-door policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 A review of the policy titled, Safe and Homelike Environment, implemented 9/1/23, revealed: In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and home like environment, allowing Level of Harm - Immediate the resident to use his or her personal belongings to the extent possible. This includes ensuring that the jeopardy to resident health or resident can receive care and services safely and that the physical layout of the facility maximizes resident safety independence and does not pose a safety risk.

Residents Affected - Few Definitions included: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas; Orderly is defined as an uncluttered physical environment that is neat and well-kept.

Policy explanation and compliance guidelines: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

General Considerations: Report any unresolved environmental concerns to the Administrator.

A review of the facility's immediate actions to remove the Immediate Jeopardy included:

1. Immediate Action:

NHA and Plant Operations Director performed environmental rounds on 2/26/2025, identified areas of concern noted and reported in the electronic maintenance records system. Work orders started in order of priority for hazards causing uneven surfaces, fall risk hazards, and items with potential to risk resident safety.

Summoned Corporate Plant Operations support team for assistance on 2/26/2025

Initiated repairs of identified areas of concern on 2/26/2025

Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025, part of repaired tiles began to shift, tiles replaced again on 2/27/2025.

Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025

400 Hall ramp missing carpet tiles replaced on 2/26/2025, carpet tile surface continues to be uneven, all carpet tiles were removed from ramp and replaced with one solid carpet piece.

On 2/27/2025 surveyors and NHA completed environmental rounds of the facility noting areas of continued concern.

List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system.

300 Hall clean out with uneven surface repaired.

99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned 24 hours a day X 7 days to establish a Level of Harm - Immediate pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from jeopardy to resident health or 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed safety 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated.

Residents Affected - Few 2. Identification of others at risk was accomplished by:

Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards.

NHA/Designee rounded facility to survey for environmental hazards.

Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing

3. Actions to Prevent Occurrence/Recurrence:

NHA, DCS (Director of Clinical Services), and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.

DCS/Designee re-educated staff on Accidents and Supervision Policy.

DCS/Designee re-educated staff on Recognizing & Reporting Hazards.

DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards.

DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.

Initiation and Assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification.

A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months or until substantial compliance is determined.

4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN (as needed) as indicated. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months.

Verification of the facility's removal plan was conducted by the survey team on 2/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The Level of Harm - Immediate facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility jeopardy to resident health or educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if safety the hazard was not repaired.

Residents Affected - Few Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a couple of the staff were not reachable, but a system was put into place for education prior to their next working day.

Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 28 105354

F-F921 Residents Affected - Few 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.

The facility's failure to provide supervision and prevent accident hazards caused serious harm and injuries to Resident #6 and placed 18 additional ambulatory residents in the memory care unit at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25.

The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D.

Findings included:

A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to

the facility on [DATE REDACTED], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation.

A review of the Situation, Background, Appearance, and Review (SBAR) Communication Form and Progress Note revealed Resident #6 had a change in condition of a fall on 1/20/25. The Situation section of the form documented status post fall, trip and fall in hallway, complaining of lower back and right leg pain. The Background section documented the resident has new pain with an intensity of 9 out of 10 (10 being the worst). The Appearance section documented status post fall in hallway, left in place due to pain on movement. 911 called. The Review and Notify section documented that the primary care clinician was notified on 1/20/2025 at 8:40 a.m. with recommendations to send to the emergency room (ER) for evaluation.

The Family Member (FM) was notified on 1/20/2025 at 8:44 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed this [AGE] year-old female had a medical history of dementia, dyslipidemia, and COPD [chronic obstructive Level of Harm - Immediate pulmonary disease]. The nursing home resident, presented to the hospital from the nursing home after a fall. jeopardy to resident health or The patient was found on the ground and complaining of right hip pain. The patient's baseline was confused, safety and she could only recognize her [FM]. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, Residents Affected - Few on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization.

A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness.

A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure.

A review of Resident #6's clinical record at the facility prior to the 1/20/25 fall with a fracture revealed a quarterly Minimum Data Set (MDS), dated [DATE REDACTED]. The cognitive pattern (Section C) showed a Brief

Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The functional abilities assessment (Section GG) revealed the resident was independent with eating, oral and toileting hygiene, and upper/lower body dressing. The resident required supervision with shower/bathing self, putting on/taking off footwear, and personal hygiene. The resident was independent with rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, walking 10 feet and walking 50 feet with two turns. The resident required partial assistance with tub/shower transfer, and supervision with walking 150 feet. The resident was always incontinent of bladder and frequently incontinent of bowel (Section H). The health conditions assessment (Section J) revealed the resident had no pain 5 days prior to the assessment, and had not fallen since admission/entry, reentry, or prior assessment.

A review of Resident #6's last Physical Therapy (PT) Discharge Summary (prior to the 1/20/25 fall with a fracture) was dated 12/26/2024 and showed the resident was able to ambulate with no assistive device with modified independence (MI) for up to 300 ft. or as tolerated on level surface with verbal cues for directional changes.

A review of Resident #6's last Fall Risk Evaluation (prior to the 1/20/25 fall with a fracture) was dated for a last known fall on 11/25/24 with a fall risk score of 9 (a score of 8 or higher indicates a fall risk).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty (related to the fall on 1/20/25). The record showed the resident Level of Harm - Immediate was in pain whenever touched. The resident had a surgical wound on the right thigh. jeopardy to resident health or safety A review of a Fall Risk Evaluation conducted on 1/26/2025 at 5:39 p.m. showed the last known fall was on 1/20/25. The resident's fall risk score was 17. Residents Affected - Few

A review of a PT Evaluation dated 1/27/2025 showed Resident #6's prior level of function (PLOF) for bed mobility and transfers was independent with a baseline on 1/27/2025 of total assistance. The PLOF for walking was supervision with rolling walker up to 200 feet with a baseline on 1/27/25 of unable.

A review of Resident #6's 5-day MDS (post fall and hospitalization ), dated 1/28/25, revealed the resident had a BIMS score of 00, indicating severe impairment. The functional abilities assessment showed the resident was dependent on eating, oral and toileting hygiene, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. The resident was dependent for rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, car transferring, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The assessment showed the resident was using a manual wheelchair. The resident was incontinent of bowel and bladder. The health conditions revealed frequent pain, no falls in the last month prior to admission/entry or reentry, no fracture related to a fall in the 6 months prior to admission/entry or reentry and had major surgery during the 100 days prior to admission.

A review of Resident #6's care plan initiated on 8/21/2024 and revised on 1/30/2025 revealed the resident was at risk for falls related to history of falls, poor safety awareness, incontinence, dementia, psychotropic medication use, and neuropathy.

The interventions for the care plan included:

Ensure resident has a safe environment: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position; handrails on walls, personal items within reach) initiated on 8/21/2024.

1/20/2025 Keep environment/walkway free of trip hazards initiated on 1/20/25 and revised on 1/30/2025.

10/25/2024 Family to assist with decluttering room for safety initiated on 11/25/2024 and revised on 1/30/2025.

2/12/2025 Scoop mattress initiated on 2/13/2025.

During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to Level of Harm - Immediate repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director jeopardy to resident health or of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean safety OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the Residents Affected - Few (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of

an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall

on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created.

An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her FM. The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall.

Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down

the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it.

On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen.

The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch.

On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated

the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research Level of Harm - Immediate a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit jeopardy to resident health or the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this safety repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself Residents Affected - Few before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area.

During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell . The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall

on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls.

An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated

she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size.

A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p. m. by the DOM with a status of Set to completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory Level of Harm - Immediate care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was jeopardy to resident health or conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a safety long time and estimated it to be approximately 6 to 8 months.

Residents Affected - Few On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs.

On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for

the safety of the residents.

During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors.

Photographic evidence was obtained.

Review of the Fall Prevention Program, implemented on 9/1/24, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy defined a fall as an event in which an individual unintentionally comes to rest on

the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere.

The policy explanation and compliance guidelines showed the facility utilized a standardized risk assessment for determining a resident's fall risk. Low/moderate risk protocols include implementation of universal environmental interventions that decrease the risk of a resident falling, including, but not limited to: A clear pathway to the bathroom and bedroom doors.

A review of the facility's immediate actions to remove the Immediate Jeopardy included:

1. Immediate Action:

Environmental rounds completed, identified areas of concern noted.

Summoned Corporate Plant Operations support team for assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Quality review completed for all current residents sustaining a fall to ensure plan of care is in place in the past 6 months, no discrepancies noted. Level of Harm - Immediate jeopardy to resident health or Medical Record Review of all residents with falls with major injury in the past 6 months conducted; no safety discrepancies noted.

Residents Affected - Few 99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025.

Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned for 24 hours a day X 7 days to establish a pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated.

2. Identification of others at risk was accomplished by:

On 2/26/25-2/27/25 The Director of Clinical Services (DCS) and designee(s) reassessed all residents residing in the facility for fall risk via Fall Risk Evaluation.

Facility implemented Activities Invitation Rounds for residents identified at risk for falls. Activities staff will encourage identified residents to attend activities of choice and document on log to establish a pattern of attendance/ preferences.

The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as at risk for falls (Fall Risk Score of 8 or higher) had safety measures, as well as resident specific interventions in place and to ensure the safety measures and resident specific interventions are also reflected on the Kardex so that the CNA's have access to this information.

Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards.

Identified environmental concerns addressed by priority level, initiated repairs and ongoing.

Record review of Resident #6 completed. Therapy screen completed on 1/22/2025; PT/OT services ongoing. Resident seen by psych provider. No changes in mood or mentation noted. Pain Management in place. Resident has orders for pharmacological pain intervention: Tylenol, Lidocaine External Patch, and Tramadol as of 2/27/25. Resident was previously on Norco, but medication was discontinued.

3.Actions to Prevent Occurrence/Recurrence:

NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.

Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility fall related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility fall related policies. Level of Harm - Immediate jeopardy to resident health or DCS/Designee re-educated staff on Abuse, Neglect, Exploitation Policy. safety DCS/Designee re-educated staff on Residents' Rights. Residents Affected - Few DCS/Designee re-educated staff on Accidents and Supervision Policy.

DCS/Designee re-educated staff on Recognizing & Reporting Hazards.

DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards

DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.

The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on

the care plan and Kardex five times weekly x 8 weeks, three times weekly x 2 weeks; twice weekly x 2 weeks, then weekly and PRN (as needed) as indicated.

A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All finding from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN as indicated. DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) daily X 5 (Business Days) for 4 weeks to ensure appropriate fall interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been update; then 3 x weekly X 4, then twice weekly x 4, then weekly x 4, then monthly x 3; and PRN as indicated. Regional DCS will review falls weekly for three months to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on

the Kardex. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months.

Verification of the facility's removal plan was conducted by the survey team on 2/28/25.

On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if

the hazard was not repaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been Level of Harm - Immediate trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a jeopardy to resident health or couple of the staff were not reachable, but a system was put into place for education prior to their next safety working day.

Residents Affected - Few Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37999

Residents Affected - Few Based 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.

Findings included:

Review of Resident #4's Admission Record revealed the resident was most recently admitted to the facility

on [DATE REDACTED]. The record included diagnoses of idiopathic hypotension, acute respiratory failure with hypoxia, unspecified pulmonary hypertension, paroxysmal atrial fibrillation, unspecified heart failure, and dependence

on supplemental oxygen.

Review of Resident #4's clinical record showed a Hospital Transfer Form, dated [DATE REDACTED] at 1:40 p.m. showed

the resident was a Full Code.

Review of a Situation, Background, Appearance, and Review/Notify (SBAR) assessment dated [DATE REDACTED] at 9:37 a.m. showed notification to the provider of resident change in condition related to food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts).

Review of Resident #4's progress note, dated [DATE REDACTED] at 1:56 p.m. showed the resident was transferred from one room to another at 1:30 p.m., and the resident was found unresponsive. Emergency Medical Transport (EMT) was called, and the physician and family were notified.

An interview was conducted on [DATE REDACTED] at 3:22 p.m. with the Director of Nursing (DON). The DON reported Resident #4 was transferred on [DATE REDACTED], and stated the resident had CPR initiated in the facility, and the physician present in the facility assisted. She stated the expectation was for staff to document CPR was initiated and EMT was called in the clinical record. A follow-up interview with the DON on [DATE REDACTED] at 3:58 p. m. confirmed the clinical record and transfer form did not reveal the resident had received CPR.

Review of the policy - Documentation in Medical Record, implemented ,d+[DATE REDACTED], showed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The compliance guidelines included:

1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

3c. Documentation shall be timely and in chronological order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 28 105354 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105354 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd Lakeland, FL 33805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37999 safety Cross Reference