Vivo Healthcare Winter Haven

In the surveyor’s words

From the most serious findings on record at Vivo Healthcare Winter Haven, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jan 22, 2021

  Based on staff and family interviews, record review and policy review it was determined the facility failed to correctly identify and protect the end of life rights of one (Resident #2) of eight sampled residents related to the resident's right to have his end of life wishes honored to not receive Cardiopulmonary Resuscitation (CPR) if found unresponsive. Resident #2 was an [AGE] year-old male with hospice enrollment and a designated family member as his power of attorney (POA), who had the legal authority to make medical decisions on his behalf. […]

• No harm, potential for more than minimal, widespreadF851Apr 10, 2025

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

• No harm, potential for more than minimal, widespreadF867Apr 10, 2025

  Based on interviews and records reviewed, the facility failed to developed and implemented action plans to correct identified quality deficiencies; measure the success of actions implemented and track performance to ensure improvements are realized and sustained, track medical errors and adverse events, analyze their causes, and implement preventive actions and mechanisms, conduct at least one Performance Improvement Plan (PIP) annually that focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis, and did not ensure the QAA Committee regularly reviews and analyzes data collected under the QAPI program and resulting from drug regimen reviews, and act on the data to make improvements. […]

• No harm, potential for more than minimal, widespreadF880Apr 10, 2025

  Based on observations, record review, and interviews, the facility failed to implement an effective infection control program related to 1.) initiating contact precautions for one resident (#154) of one resident suspected and treated for a highly contagious condition, 2.) failed to clean shared equipment appropriately and store it in a sanitary manner, and 3.) failed to promote good hand hygiene by limiting the length of fingernails of direct care staff. Findings included: 1. Review of Resident #154's Admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses of diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #154's Medication Administration Record on 4/7/25 at 3:30 p.m. […]

• No harm, potential for more than minimal, widespreadF881Apr 10, 2025

  Based on observations, record reviews, and interviews the facility failed to establish an effective antibiotic stewardship program related to the antibiotic use protocols and monitoring the use of antibiotics. Findings included: Review of February 2025's Infection Control Log, 2/1 to 2/28/25, showed the facility had a total of 7 infections effecting 7 residents for the month. The log revealed the facility had 3 Urinary Tract Infections (UTIs), one mouth, one eye, one acute kidney injury, and one leg cellulitis infections. […]