Valencia Hills Health And Rehabilitation Center
VALENCIA HILLS HEALTH AND REHABILITATION CENTER in LAKELAND, FL — inspection on April 30, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #73's active Care Plan dated 7/25/25 revealed Resident #73 has impaired visual function related to Glaucoma.
The interventions for this care plan state to observe, document and report as needed any signs or symptoms of acute eye problems. On 4/29/2026 at 12:46 p.m., an interview was conducted with Staff A, Certified nursing assistant (CNA).
Staff A, remembers there was an eye doctor that would see the residents here, and she is not sure if they currently still have this process in place.
She said, if a resident reported they needed to see an eye doctor, she would report this to her nurse.
Staff A said, if she recalls accurately the Unit Manager would handle the arrangements to see an eye doctor. On 4/29/2026 at 12:54 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN).
Staff B said, Resident #73 did request a couple months ago that she would like to see an ophthalmologist.
Staff B looked for a logbook to report this, could not find the logbook for vision care needs.
Staff B said they didn't have a Unit Manager at the time, so she reported this to the previous Director of Nursing (DON). On 4/29/2026 at 12:54 p.m., an interview was conducted with the interim Director of Nursing (DON).
The DON stated the process for a vision exam is to notify the nurse or supervisor first.
Then determine if the resident would prefer the in-house optometrist, or if an outpatient appointment is needed.
The DON stated they have two staff members that will handle appointment arrangements and transportation.
The DON said, she is not aware of Resident #73 requesting to have a vision appointment for over two months.
The DON acknowledged the process did not get the outcome expected for Resident #73.
Review of the Resident Rights Policy with no revision date revealed the following.
Policy: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
The facility must protect and promote the rights of the resident.
The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, and reprisal from the facility.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
105301 04/30/2026
Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810
staff who were able to say they saw the two residents in the room together.
The NHA stated one
incident.
The NHA stated the care staff were responsible for supervising the halls of the unit.
A review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revealed the following: It is the policy of the facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Services Director, and the Director of Nursing.
The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents.
Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.
Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Neglect occurs when the facility is ware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm.
Person centered care: For purposes of this subpart, person centered-care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.
Sexual abuse: Sexual abuse is non-consensual sexual contact of any type with a resident.
The facility must determine whether the resident(s) have the capacity to consent to sexual activity.
105301 04/30/2026
Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810
Review of Resident #131's active orders showed:-Donepezil HCl (hydrochloride) Tablet 5 mg; Give 10 mg by mouth one time a day for dementia.2. On 04/29/2026 at 4:30 PM a medication observation was conducted for with Staff D, LPN for Resident #194.Staff D obtained a blood glucose level of 234.
Staff D then dispensed the Humalog KwikPen and turned the dial to show 3 units.
Staff D, LPN stated she does not prime the pen prior to administration.
Staff D administered the dose in the left lower abdomen and held dose knob for approximately 2 seconds.Review of Resident #194's admission Record showed he was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus type 2.Review of Resident #194 active orders showed: -HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Lispro) Inject as per sliding scale: if 0 - 110 = 0 units for blood sugar less than 70 notify physician; 111 - 149 = 1 units; 150 - 199 = 2 units; 200 - 249 = 3 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350 - 399 = 6 units ; 400+ = 6 units for blood sugar greater than 399 give 6 units and notify physician, subcutaneously before meals and at bedtime for DM (diabetes mellitus).On 04/30/2026 at 1:00 PM an interview was conducted with the Interim Director of Nursing (DON).
She said she has not provided education to staff regarding insulin pen priming.
She was not able to provide a proper demonstration of how to prime an insulin pen. DON said it was necessary to prime an insulin pen to provide the resident with the correct dose of insulin.
Reviewed with DON regarding findings of the medication administration observations.
The DON confirmed the correct dose of milligrams should have been administered, and the nurse should have primed the insulin-pen.
Review of the manufacturer's KwikPen U-100 instructions for use 3mL single-patient-use pen found on the manufacturer's website at: https://uspl.lilly.com/humalog/humalog.htm#ug1 showed the following:Step 5: Priming your Pen.
Prime before each injection.-Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly.-If you do not prime before each injection, you may get too much or too little insulin.Giving your injectionStep 11:-Insert the needle into your skin.-Push the dose knob all the way in.-Continue to hold the dose knob in and slowly count to 5 (5 seconds) before removing the needle.
Review of the Policy Administering Medications with a revision date of April 2019 showed: Medications are administered in a safe and timely manner, and as prescribed. 10.
The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
105301 04/30/2026
Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810
Review of Resident #130's progress notes revealed a nursing note on 3/13/2026 at 10:11 p.m. showing Resident #130 had swelling of the right arm and right hand, felt hard and a little warm to touch.
The resident's cast was removed from this arm on 2/19/2026 from a previous fracture.
The note also said Resident #130 had range of motion within normal limits (ROM WNL), hospice and facility physician were notified.
Review of Resident #130's progress notes revealed a nursing note on 3/14/2026 at 6:15 a.m. that a new order was placed for a venous ultrasound of the right upper extremity.
Review of Resident #130's progress notes revealed a nursing note on 3/15/2026 at 9:56 p.m. that stated a call was placed to a mobile radiology vendor regarding Resident #130's doppler that was ordered.
The facility was told someone would visit that same day however they had not come to do the venous doppler.
Review of the procedure results showed on 3/17/2026 at 11:01 a.m. Resident #130 had an occlusive radial deep venous thrombosis.
Review of Resident #130's care plan showed Resident #130 was at risk of cardiac complications.
There was an intervention to notify physician of significant abnormalities and observe/document/report any color/warmth of extremities.
During an interview on 4/30/2026 at 1:40 p.m.
Staff Q, Certified Nursing Assistant (CNA) stated swelling was to be reported to the nurses right away who will then check on the resident.
During an interview on 4/30/2026 at 1:42 p.m.
Staff P, Licensed Practical Nurse (LPN) stated change in condition, such as swelling, was to be reported immediately.
This included night shift nurses as there is an on call physician.
Staff P did not know why there was a delay in testing after swelling was found on Resident #130's arm.
Staff P said if radiology was ordered through a vendor and they did not show up, the facility would follow up with the vendor within that same shift.
During an interview on 4/30/2026 at 12:48 p.m. the Director of Nursing (DON) stated swelling in residents with a history of chronic heart failure was to be reported right away. If this occurred during night shift, staff should not wait until morning to report it.
The DON said if an outside vendors was to conduct a procedure but had not shown up yet, staff must call again to find out, what happened.
Nurses are to confirm with the doctor and ensure the test(s) are ordered stat.
The DON said she was unsure why there was a delay in care especially if there was swelling involved.
Review of the facility's LPN position description revealed a Basic function: To deliver nursing care to residents of this facility.
Essential Function: .3.
Makes observations and reports pertinent information related to the care of the resident.
The Coordination of Care: 1. Co-workers are informed of changes in residents conditions or of any other changes occurring on the unit. 2.
Information is relayed to other members of the health care team (LE., physicians.)
Review of the facility's Registered Nurse (RN) position description revealed a Basic Function: To plan and deliver nursing care to patients/residents requiring long-term of rehabilitative care.
Essential Functions:.7.
Maintains knowledge of necessary documentation requirements.
The Coordination of Care: 1. Co-workers are informed of changes in residents conditions or of any other changes occurring on the unit. 2.
Information is relayed to other members of the health care team (LE., physicians.)
105301 04/30/2026
Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810
concentration will be as follows: Type of solution = Chlorine, Minimum concentration = 50-100 ppm,
105301 04/30/2026
Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810
Review of the policy - Pneumococcal Vaccine, revised August 2016,
pneumonia/pneumococcal infections.
The interpretation and implementation revealed the following:1.
Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contradicted or the resident has already been vaccinated.2.
Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission.4.
Pneumococcal vaccines will be administered to residents (unless medically contradicted, already given, or refused) per our facilities physician-approved Pneumococcal vaccination protocol.5.
Residents/ representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each residence medical record indicating the date of the refusal of the pneumococcal vaccination.6.
For residents who received the vaccines, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the residence medical record.
Review of the policy - Infection Prevention and Control Program, undated, revealed And in infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.1.
The IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment.
The program is reviewed annually and updated as necessary.2.
The program is based on accepted national infection prevention and control standards.The elements of the IPCP included but not limited to:1.
Coordination and Oversight d.
Surveillance data and reporting information is used to inform the committee of potential issues and trends.
Some examples of committee reviews may include:3.
Surveillance and reporting b.
Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and dictating unusual pathogens with infection control implications.4.
Antibiotic Stewardshipa.
Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities.b.
Medical criteria in standardized definitions of infections are used to help recognize and manage infections.6.
Outbreak Management a.
Outbreak management is a process that consists of: (1) determining the presence of an outbreak; (3) preventing the spread to other residents; (6) educating the staff and the public;7.
Prevention of Infection a.
Important facets of infection prevention include:(3) Educating staff and ensuring that they adhere to proper techniques and procedures;9.
Monitoring Employee Health and Safetya.
The facility has established policies and procedures regarding infection preventions and control among employees, contractors, vendors, visitors, and volunteers, including:b.
Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.(1) The facility provides personal protective equipment, checks for its proper use, and provides appropriate means for needle disposal.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.