Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vivo Healthcare Winter Haven during CMS and state inspections, most recent first.
The facility did not submit required PBJ staffing data for a full quarter, as confirmed by review of CMS reports. The NHA was unaware of the missed submission, citing reliance on a third-party company, and the facility lacked a policy or procedure for PBJ reporting expectations.
The facility did not develop or implement action plans to address quality deficiencies, failed to track and analyze medical errors and adverse events, and did not conduct required annual Performance Improvement Plans. Despite claims of regular QAPI/QAA meetings with the DON, Medical Director, and other department heads, the facility could not provide any documentation or signature pages to verify these activities, as the QAPI/QAA book was missing.
The facility did not implement effective infection control measures, including failing to initiate contact precautions for a resident treated for a contagious GI condition, not properly cleaning and storing shared medical equipment, and allowing direct care staff to have long or artificial fingernails, contrary to CDC guidance and facility policy.
The facility did not maintain an effective antibiotic stewardship program, as infection control logs were incomplete, lacking key information such as onset and resolution dates, culture results, and infection site details. The DON confirmed that antibiotics were sometimes prescribed without proper cultures or adherence to established protocols, and the Infection Preventionist had not consistently applied required criteria or maintained necessary documentation. These actions and omissions resulted in the facility's failure to follow its own antibiotic stewardship policy.
Multiple resident rooms and common areas were found with bio growth, soiled and damaged surfaces, missing or broken equipment, and incomplete maintenance, while the facility lacked comprehensive maintenance policies and tracking. The Director of Maintenance relied on an electronic work order system without scheduled surveys or specific protocols for bio growth, resulting in unresolved environmental deficiencies.
Surveyors identified a medication error rate of 34.15% during observed medication passes, with errors including missed doses, administration of expired medications, and failure to follow physician orders. LPNs were observed searching for unavailable medications, attempting to administer incorrect or expired drugs, and not following proper procedures for medication reconciliation or documentation. The DON confirmed that staff did not always notify physicians or the pharmacy when medications were unavailable, and several ordered medications were not administered to residents following hospital readmission.
Live bugs and insect feces were observed in multiple rooms and common areas, with both staff and a resident reporting frequent pest sightings. The pest log showed repeated pest activity over several months, and the Director of Maintenance lacked a comprehensive written maintenance policy, relying instead on an electronic work order system and biweekly pest control services.
The facility did not promptly resolve or document grievances related to delayed call light responses and inadequate staff assistance, as repeatedly raised by residents in council meetings and individual complaints. Despite ongoing concerns, the formal grievance process was not consistently followed, and investigations were incomplete or not documented, leaving residents' issues unresolved.
The facility did not ensure accurate PASRR screenings for several residents with mental health or intellectual disability diagnoses, resulting in missing or incomplete documentation of conditions such as depression, bipolar disorder, cerebral palsy, and dementia. In multiple cases, PASRR forms were not updated to reflect new diagnoses or were left incomplete, and the interdisciplinary team did not consistently review or correct these records as required by facility policy.
Three residents did not receive care as outlined in their care plans, including failures to properly administer and monitor oxygen therapy, supervise nebulizer treatments, and provide prescribed splints/orthotics for contracture management. Staff did not consistently follow physician orders or document required interventions, resulting in unmet care needs.
Four resident bathrooms were found without accessible call light pull strings, as confirmed by direct observation and staff interviews. The maintenance process relied on an electronic work order system, but no work orders were placed to address the missing call lights in the affected rooms, despite facility policy requiring immediate reporting and resolution of such issues.
Several residents who required assistance with ADLs were observed with visible facial hair, despite documentation showing that care was provided and no refusals were recorded. Interviews with residents, their representatives, and staff confirmed that facial grooming was expected and should be included in daily care, but it was not performed as required by care plans and facility policy.
Two residents did not receive multiple ordered medications following admission or readmission due to failures in medication reconciliation, ordering, and administration. Staff did not consistently notify physicians or the pharmacy when medications were unavailable, and documentation of these actions was lacking, despite facility policy requiring such steps.
Two residents on pureed diets were served meals with unidentifiable food items, and staff were unable to inform them about what they were eating due to missing information on meal tickets. One resident, with multiple health conditions, was assisted by staff who could not identify the foods, while another cognitively intact resident reported receiving the same foods daily and not being offered alternatives. The dietary manager also struggled to identify the foods served, and facility policies requiring resident involvement and information about meals were not followed.
Two residents independently self-administered nebulizer treatments without physician orders, assessments, or care plan interventions addressing self-administration. Nursing staff did not remain present during treatments, and required documentation and interdisciplinary team assessments were not completed, despite facility policy mandating these steps for self-medication.
A resident's care plan was not updated to reflect the removal of an indwelling urinary catheter, resulting in outdated interventions and goals remaining in place. Staff interviews and documentation confirmed the catheter had been removed weeks prior, but the care plan continued to address catheter care despite the resident no longer having one.
A resident with a history of multiple fractures and recent surgery was found with a mesh pad covering a black area on the left ankle that had not been assessed, documented, or treated for about a month. Staff interviews and record reviews revealed no physician orders or monitoring of the site, and the care plan lacked specific instructions for its care, resulting in a deficiency in appropriate wound management.
A resident with severe upper extremity contractures and cognitive impairment was not provided with the ordered splints and orthotics for contracture management over several days. Staff were unaware of the splinting requirements, and there was no documentation or evidence that the prescribed interventions were implemented, despite clear physician orders and care plan directives.
A resident with multiple complex diagnoses, including neuromuscular bladder dysfunction and quadriplegia, did not have proper physician orders specifying the diagnosis, Foley or balloon size, or instructions for catheter changes. The DON confirmed the absence of required documentation and orders, despite facility policy requiring appropriate catheter care.
A resident with severe cognitive impairment and a history of swallowing difficulties was observed coughing during meals and was served foods inconsistent with prescribed diet orders, such as garlic bread instead of appropriate mechanically soft options. Despite multiple changes in diet orders and recommendations for supervision, staff did not consistently implement or monitor dietary interventions, and failed to obtain or review key hospital records related to swallowing assessments. The resident also accessed unsafe foods from other sources, and staff did not adequately address these issues.
Two residents did not receive oxygen therapy as ordered, with oxygen concentrators set at incorrect levels and incomplete documentation of administration and monitoring. Additionally, two other residents had nebulizer masks left unbagged on bedside tables after use, contrary to facility policy requiring proper storage of respiratory equipment. Staff interviews confirmed that physician orders and facility procedures were not consistently followed.
A resident with dementia and multiple psychiatric diagnoses exhibited frequent yelling and self-hitting behaviors, but staff did not consistently monitor, document, or address these behaviors through behavioral health services. Staff interviews revealed uncertainty about documentation requirements, and records showed no evidence of behavioral monitoring or interventions, despite facility policy requiring such care.
The facility did not maintain accurate medical records for two residents, including repeated identical and missing vital sign entries, incomplete documentation of medication administration, and continued documentation of catheter care after a catheter had been removed. Staff recorded care and observations that did not occur, contrary to facility policy requiring factual and complete documentation.
A resident with a history of falls and multiple medical conditions experienced a fall, but the facility did not notify the resident's representative or family at the time of the incident. Documentation showed the notification section was left blank and there was no record of timely communication. The family was only informed after the resident was sent to the ER for further treatment.
Failure to Submit PBJ Staffing Data for Required Quarter
Penalty
Summary
The facility failed to submit the required Payroll Based Journal (PBJ) staffing data for the first quarter of Fiscal Year 2025, covering the period from October 1 to December 31. Review of the CMS PBJ Staffing data report (CASPER Report 1705D) confirmed that no staffing data was submitted for this timeframe. During an interview, the Nursing Home Administrator (NHA) stated he was not involved with PBJ submissions and was unaware that the facility had failed to report the data, noting that a third-party company was responsible for submitting their PBJ staffing hours. The NHA also mentioned that he could access the relevant report but rarely reviewed it. Additionally, the facility did not have a policy or procedure outlining the expectations for reporting PBJ staffing hours.
Failure to Implement and Document QAPI Program Activities
Penalty
Summary
The facility failed to develop and implement action plans to correct identified quality deficiencies, as well as to measure the success of actions taken and track performance to ensure improvements were realized and sustained. The facility also did not track medical errors and adverse events, analyze their causes, or implement preventive actions and mechanisms. Additionally, the facility did not conduct at least one Performance Improvement Plan (PIP) annually that focused on high-risk or problem-prone areas, as required by their own policies and federal regulations. Record review revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program policy required the establishment of a Quality Assessment and Assurance (QAA) Committee, regular meetings, data collection and analysis, and the development and implementation of corrective action plans. The policy also required the QAA Committee to regularly review and analyze data, including data from drug regimen reviews, and to act on this data to make improvements. However, there was no documentation available to demonstrate that these activities were being carried out as required. During an interview, the Nursing Home Administrator stated that the QAPI/QAA program met at least once a month and included the DON, Medical Director, and other interdisciplinary team members. Despite this, the Administrator was unable to provide signature pages or any other documentation related to the meetings, as the QAPI/QAA book was missing and its whereabouts were unknown. This lack of documentation meant there was no evidence to support that the facility was following its own QAPI policies or federal requirements regarding quality assurance and performance improvement activities.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in several key areas. For one resident who was suspected and treated for a highly contagious gastrointestinal condition, staff did not initiate contact precautions as required. Despite the resident experiencing multiple episodes of diarrhea and being treated with antibiotics for possible Clostridioides difficile (C. diff), there was no signage or personal protective equipment (PPE) outside the resident's room, and no documentation of transmission-based precautions in the facility records. Staff interviews revealed that precautions were not implemented while awaiting laboratory confirmation, contrary to facility policy, which allows for empiric precautions based on symptoms. Additionally, staff did not consistently clean and store shared medical equipment in a sanitary manner. During medication administration, an LPN was observed wiping a glucometer and blood pressure cuff with disinfectant wipes but then placing them directly on the resident's over-bed table without a barrier. The same staff member also failed to clean a thermometer after use and stored it with other equipment without proper disinfection. These actions were not in accordance with the facility's policy on routine cleaning and disinfection, which requires proper cleaning to prevent the development and transmission of infections. The facility also failed to promote good hand hygiene practices among direct care staff. Multiple staff members, including two LPNs and the DON, were observed with artificial and/or long fingernails extending beyond the fingertips, some of which were painted or acrylic. The DON acknowledged that anyone providing care should have clean, short fingernails, but the facility did not provide a dress code policy when requested. CDC guidance referenced in the report states that natural nails should not extend past the fingertip and artificial nails should not be worn when providing direct care, as germs can persist under artificial nails even after hand hygiene.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective antibiotic stewardship program, as evidenced by incomplete and inconsistent documentation of infection events and antibiotic use. Infection control logs for February and March 2025 showed missing onset and resolution dates for most infections, incomplete information on whether infections were healthcare-associated, and lack of documentation regarding isolation requirements. Many infections, including urinary tract infections (UTIs) and respiratory infections, lacked culture results or evidence of appropriate diagnostic testing, and the logs did not consistently indicate whether infections were community-acquired or nosocomial. Additionally, the logs did not break down infections by site or report dates to the Infection Control/Performance Improvement Committee as required. Interviews with the Director of Nursing (DON) revealed that the facility did not consistently follow its own antibiotic stewardship protocols. The DON acknowledged that not all infections were cultured before antibiotics were prescribed, and that antibiotics were sometimes ordered prophylactically without clear documentation of appropriateness. The DON also confirmed that the Infection Preventionist (IP) had not been applying McGeer criteria during her tenure, and there was no evidence of follow-up or documentation regarding antibiotic use reviews with physicians or the Quality Assurance committee. The facility's process for reviewing antibiotic appropriateness upon admission or readmission was inconsistently applied, and there was no clear tracking of antibiotic utilization rates. A review of the facility's written policy on antibiotic stewardship outlined specific responsibilities for the IP, DON, and administrator, as well as protocols for laboratory testing, monitoring, and documentation. However, the observed practices did not align with these policies. Required documentation, such as action plans, assessment forms, data collection forms, and meeting minutes, was not maintained or was incomplete. Data from antibiotic stewardship monitoring activities was not consistently discussed in QAPI meetings, and there was a lack of feedback reports and records related to staff education. These deficiencies contributed to the facility's failure to implement an effective antibiotic stewardship program.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three common areas across multiple wings. Observations over several days revealed multiple deficiencies, including bio growth on ceilings near fire sprinkler heads, brown rough surfaces over toilet seats, unfinished and unpainted walls, missing baseboards, broken drawers, broken toilets, pest feces in showers, and the absence of call light systems or lights in some bathrooms. Common areas also exhibited bio growth, loose ceiling tiles, and bio growth in lighting fixtures. Photographic evidence was obtained to document these findings. Interviews and record reviews indicated that the Director of Maintenance (DOM) did not conduct comprehensive facility surveys or submit reports to the Nursing Home Administrator. Maintenance issues were addressed through an electronic work order system, but there was no written policy for scheduled maintenance or for addressing bio growth. Facility documents showed that many maintenance issues, such as patched but unpainted walls and missing floorboards, were not tracked or addressed in the work order system. The facility's cleaning policy required cleaning of visibly soiled surfaces, but there was no specific policy for bio growth. No work orders were found addressing the observed deficiencies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with observations revealing a 34.15% error rate during medication administration. Surveyors observed 41 medication administration opportunities and identified 14 errors involving four residents. These errors included missed doses, administration of expired medications, incorrect medication preparation, and failure to follow physician orders and facility policies. One incident involved a nurse searching for a prescribed calcium supplement and instead attempting to administer a different formulation before realizing the error. The nurse informed the resident that the correct medication was owed, but the medication order had been changed shortly after the observation. In another case, a nurse attempted to administer Midodrine to a resident despite the resident's blood pressure being above the hold parameter, only stopping after being prompted to review the order. The same nurse also prepared to administer expired insulin before obtaining a replacement from the emergency drug kit, but did not properly prime the insulin pen according to facility policy. Additional deficiencies included a nurse being unable to administer a prescribed antidepressant due to its unavailability, and another nurse failing to provide multiple ordered medications to a recently hospitalized resident due to missing medications and lack of reconciliation upon the resident's return. In several cases, staff did not follow procedures for obtaining or documenting unavailable medications, and there was a lack of timely communication with the pharmacy and physicians regarding medication availability. These actions and inactions directly contributed to the high medication error rate identified during the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control management system, as evidenced by the presence of live crawling bugs and insect feces in nine resident rooms and common areas. Observations were made on multiple occasions, and both staff and a resident reported frequent sightings of pests such as roaches and ants throughout the facility. The pest log documented repeated occurrences of roaches, ants, flies, spiders, and fleas across various wings over several months. A resident specifically pointed out pest droppings under her nightstand, confirming ongoing pest activity in her room. Interviews with staff revealed that while the Director of Maintenance (DOM) conducted daily walkthroughs and addressed issues as they arose, there was no comprehensive survey or written policy outlining daily, weekly, monthly, or annual maintenance procedures. The DOM relied on an electronic maintenance work order system for tracking and resolving pest issues, and pest control services were scheduled biweekly. The facility's pest control policy required a written agreement with an outside service and a reporting system for pest issues, but the observed and documented pest activity indicated that these measures were not effectively implemented.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances voiced by residents, particularly those raised during Resident Council meetings over a period of several months. Resident Council minutes from three separate months documented ongoing concerns about delayed call light responses and inadequate staff assistance, especially during evening and weekend shifts. Despite these recurring complaints, a review of the facility's grievance logs revealed no corresponding entries or documentation of these issues being formally addressed as grievances. Two residents, both cognitively intact, reported continued difficulties in receiving staff assistance. One resident filed a grievance regarding lack of staff assistance, but the investigation only noted the nurse aide's location at the time and did not document notification of the resident's representative. The other resident filed a grievance about both staff assistance and maintenance of an air mattress; the investigation only addressed the mattress issue, leaving the staff assistance concern unresolved and the resolution date section blank. Both residents continued to report ongoing problems with staff assistance during interviews. Interviews with facility staff, including the Activity Director and Social Service Director (who also served as the Grievance Coordinator), confirmed that while concerns were discussed in meetings and some actions were taken, the formal grievance process was not consistently followed. The facility's own policy requires that all grievances, including those voiced during Resident Council meetings, be documented, investigated, and resolved promptly, with appropriate follow-up and communication to the resident. However, the absence of documentation and incomplete investigations indicate that these procedures were not adhered to in these cases.
Failure to Maintain Accurate PASRR Screenings for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to maintain accurate Pre-admission Screening and Resident Review (PASRR) screenings for eight residents out of a sample of 52. In several cases, residents were admitted with mental health or intellectual disability diagnoses that were not accurately reflected in their PASRR Level I screenings. For example, one resident with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR that did not include these conditions, and no rescreen was performed to determine if a Level II evaluation was needed. Another resident with multiple mental health diagnoses and behavioral issues had a PASRR that did not indicate any mental illness or history of mental health services, nor did it reflect the primary diagnosis of Alzheimer's disease. Additional deficiencies were noted where residents' PASRR screenings failed to include relevant diagnoses such as cerebral palsy, depression, anxiety, and mood disorders. In some cases, the PASRR forms were outdated or incomplete, with sections left blank or failing to address significant mental health or intellectual disability conditions. For instance, one resident's PASRR did not mention a diagnosis of cerebral palsy, and another's did not address a mood disorder despite it being present in the medical record. There were also instances where the PASRR was not updated to reflect new or changed diagnoses after admission. Interviews with facility leadership confirmed that the expectation is for the interdisciplinary team to review PASRR documentation upon admission and complete a new PASRR if the information is incorrect or incomplete. The facility's policy requires accurate and timely coordination with the PASRR program, including maintaining up-to-date records and referring residents for Level II evaluations when necessary. However, the findings indicate that these procedures were not consistently followed, resulting in inaccurate or incomplete PASRR screenings for multiple residents.
Failure to Follow Comprehensive Care Plans for Respiratory, Oxygen, and Contracture Management
Penalty
Summary
The facility failed to follow comprehensive, person-centered care plans for three residents, resulting in deficiencies related to respiratory care, oxygen therapy, and contracture management. For one resident with COPD, observations revealed that the nebulizer mask was left unbagged on the overbed table, and the resident self-administered nebulizer treatments without a physician's order or assessment for self-medication. The nurse did not remain with the resident during the treatment, and the oxygen concentrator was set below the physician-ordered rate on multiple occasions. The care plan required staff to administer medications and oxygen as ordered, and to monitor lung sounds, but these interventions were not consistently followed. Another resident receiving oxygen therapy via nasal cannula was observed multiple times with the oxygen concentrator set below the physician-ordered rate of 2 liters per minute. Documentation in the Treatment Administration Record was incomplete, with several shifts lacking evidence that oxygen therapy was monitored as required. The care plan for this resident included interventions to provide oxygen as ordered, but these were not consistently implemented, as confirmed by staff interviews and record review. A third resident with severe cognitive impairment and upper extremity contractures was not observed wearing prescribed splints or orthotics during multiple visits, and no such devices were visible in the room. Staff interviews revealed a lack of awareness regarding the resident's need for splints/orthotics, and review of the care plan and physician's orders confirmed that the resident was to wear specific splints and a palm guard for a set duration each week. There was no documentation of the resident receiving assistance with these devices or of any refusals, indicating that the care plan interventions were not followed.
Failure to Maintain Accessible Call System in Resident Bathrooms
Penalty
Summary
The facility failed to maintain an effective resident call system in four specific resident rooms, as evidenced by the absence of call light pull strings in the bathrooms of rooms #204, #207, #403, and #609. Observations conducted on two separate dates confirmed that the call light pull strings were missing in these locations. Interviews with the Nursing Home Administrator revealed that he was aware of the broken call light pull strings in these rooms. The Director of Maintenance stated that while he conducts daily walkthroughs and addresses issues as they arise, there is no comprehensive survey or written policy for regular maintenance checks, and the process is managed through an electronic maintenance work order system. A review of facility documentation showed that although the electronic maintenance work order system includes a weekly task to test the nurse call system, there were no work orders placed for call light parts to address the concerns in the affected rooms during the relevant period. The facility's policy requires that call systems be accessible to residents at each toilet and bathing facility, and that staff report problems immediately to supervisors or maintenance. However, the lack of work orders and missing call light pull strings indicate that these procedures were not followed in the identified rooms.
Failure to Provide Facial Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming assistance, specifically shaving facial hair, for four residents who required help with activities of daily living (ADL). Observations revealed that these residents had visible facial hair, such as white or gray patches on their chins, despite documentation indicating that ADL care was provided and no refusals of care were recorded. Interviews with the affected residents and their representatives confirmed that the presence of facial hair was undesirable and that assistance was expected but not provided. Review of care plans for these residents showed that they required varying levels of assistance with personal hygiene, ranging from supervision to total dependence. None of the care plans documented any behaviors or refusals related to personal grooming, and staff interviews indicated that facial grooming should be part of daily ADL care for both male and female residents. Staff members, including CNAs and LPNs, stated that female residents should not have facial hair and that grooming was expected to be completed during morning care and on bath/shower days. The facility's policy on grooming facial hair outlined specific procedures for assisting residents with shaving to maintain proper hygiene. However, despite these policies and staff expectations, the observed residents continued to have facial hair, and there was no documentation of refusal or behavioral issues that would have prevented grooming. This indicates a failure to follow through with the required assistance for personal grooming as outlined in the residents' care plans and facility policy.
Failure to Reconcile and Provide Medications as Ordered for New Admissions
Penalty
Summary
The facility failed to reconcile, obtain, and provide medications as ordered for two residents who were recently admitted or readmitted. For one resident with a history of seizures, brain neoplasm, myasthenia gravis, and chronic pain syndrome, multiple scheduled medications were not administered as ordered following admission. The resident's medication administration record (MAR) showed missed doses of several critical medications, including those for seizure control, pain management, and chronic conditions. The facility did not document physician notification or obtain orders to hold or adjust medications when they were unavailable, and some medications were not available in the facility's stock or electronic dispenser. For another resident with chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension, the MAR indicated that several prescribed medications were not administered after readmission. During medication administration, an LPN was observed unable to provide multiple ordered medications, including antibiotics, antihypertensives, and medications for heart failure and nausea. The staff member did not document that the pharmacy or physician was notified about the missing medications, despite facility policy requiring such notification when medications are unavailable or late. Facility policies reviewed indicated that medications should be administered as ordered and that the physician must be contacted if medications are unavailable or delayed. The policies also outlined procedures for medication reconciliation and ordering upon admission or readmission. However, in both cases, there was a lack of timely reconciliation, ordering, and administration of medications, as well as insufficient documentation of communication with physicians or the pharmacy regarding unavailable medications.
Failure to Provide Identifiable Pureed Foods and Inform Residents of Meal Contents
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and self-determination by not serving identifiable foods to two residents on pureed diets. In both cases, meal tickets did not specify the food items being served, and staff members assisting with feeding were unable to identify the pureed foods on the residents' trays. Staff expressed uncertainty about the contents of the meals and acknowledged that they would not be able to inform residents or their families about what was being served, nor could they confirm the absence of allergens. One resident with Alzheimer's disease, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive was observed being assisted with meals where neither the assisting staff nor the dietary manager could identify the pureed food items. The menu for the day listed specific items, but these were not reflected on the meal ticket or easily identifiable on the plate. Staff confirmed that the meal ticket lacked information about the food items, and the dietary manager verified the unidentified foods after checking in the kitchen and with the resident's tray. Another resident with COPD, hypertension, dysphagia, and anemia, who was cognitively intact, reported eating the same foods daily and not being offered alternatives. This resident was observed eating only oatmeal, stating that the other pureed items were unidentifiable and unappealing. The dietary manager was also unable to immediately identify the foods served and confirmed that one item (sausage) was not on the menu. Facility policies reviewed indicated that residents' preferences should be assessed and that they should be informed about their meals, but these practices were not followed.
Failure to Assess and Care Plan for Resident Self-Administration of Nebulizer Treatments
Penalty
Summary
The facility failed to obtain physician orders, conduct assessments, or develop care plans for two residents who were self-administering nebulizer treatments. Observations revealed that both residents independently managed their nebulizer treatments without nursing staff remaining present during administration, as required by facility policy. In both cases, the nebulizer equipment was left un-bagged on bedside tables after use, and the residents reported that nurses provided the medication and set up the equipment but did not stay in the room during the treatment. Review of the medical records for both residents showed no physician orders authorizing self-administration of nebulizer treatments, no documentation of assessments to determine their ability to self-administer, and no care plan interventions addressing self-administration. Both residents had diagnoses including COPD and required respiratory treatments, with cognitive assessments indicating intact cognition. However, their care plans only addressed general respiratory care and did not include any provisions for self-administration of medications or storage arrangements for nebulizer equipment. Interviews with staff, including an LPN and the DON, confirmed that the facility did not have any residents formally assessed or care planned for self-administration of nebulizer treatments. The DON stated that the process for nebulizer treatments required nursing staff to remain with the resident throughout the procedure, and that any resident self-administering should have an order, assessment, and care plan in place. Facility policies also required interdisciplinary team assessment and documentation before allowing self-administration, none of which were completed for the residents involved.
Failure to Revise Care Plan After Catheter Removal
Penalty
Summary
The facility failed to accurately revise the care plan and related interventions for a resident with a history of an indwelling urinary catheter. The resident's care plan continued to include interventions and goals related to catheter care, even after the catheter had been removed. Observations and interviews confirmed that the resident did not have a urinary catheter at the time of the survey, and the resident reported that the catheter had come out approximately three weeks prior. Documentation review showed that the catheter was found on the bed with the balloon deflated, and the physician had ordered it to be left out to monitor the resident's condition without it. Despite the removal of the catheter and the absence of a current physician order for catheter use, the care plan was not updated in a timely manner to reflect the resident's current status. Staff interviews revealed confusion regarding the resident's catheter status, with some staff initially believing the resident still had a catheter. The facility's policy requires that comprehensive care plans be developed and revised to reflect the resident's current needs, but this was not followed in this case.
Failure to Assess, Document, and Treat Surgical Wound
Penalty
Summary
The facility failed to assess, document, and treat a surgical wound for one resident with a history of multiple fractures and recent surgical interventions. The resident was observed with a mesh pad covering a black area on the left ankle, which had reportedly been in place for about a month. Despite the presence of this surgical site, there were no physician or surgeon orders regarding its care, and the site was not mentioned in weekly skin checks or documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The care plan referenced potential or actual skin impairment but did not include specific interventions or follow-up instructions for the left ankle surgical site. Interviews with staff, including the DON and an LPN, confirmed that the area had not been recently assessed or monitored, and the wound specialist had not provided recent recommendations. The facility's documentation policy requires accurate and complete records of resident care, but the medical record lacked sufficient detail about the left ankle surgical site. This lack of assessment, documentation, and treatment for the surgical wound constituted a deficiency in providing appropriate care according to orders, resident preferences, and goals.
Failure to Implement Contracture Management Program with Splints/Orthotics
Penalty
Summary
A deficiency occurred when a resident with severe upper extremity contractures and cognitive deficits was not provided with the prescribed splints and orthotics as part of her contracture management program. Over a three-day observation period, the resident was repeatedly seen lying in bed with contracted hands and fingers, and at no time were splints or orthotics observed on her or present in her room. Multiple staff members, including CNAs and an LPN, were unaware of any splint or orthotic use for the resident, and there was no documentation on the CNA task sheet or care plan indicating their application. Further investigation revealed that the resident had physician orders and care plan interventions specifying the use of a right elbow extension splint, right resting hand splint, and left palm guard for six hours per day, five days a week, to be applied and removed by nursing staff. Occupational therapy records confirmed the need for orthotic management, and the resident had been referred to Restorative Nursing for ongoing contracture management after being discharged from OT. However, staff interviews and record reviews indicated that these interventions were not being implemented, and there was no documentation of the resident receiving assistance with splints or orthotics, nor any record of refusal. The resident's medical history included diagnoses of dysphagia, contractures in multiple joints, chronic pain, anxiety, and dementia, with substantial assistance required for most ADLs. The facility's own policies required nursing staff to provide restorative services, including splint or brace assistance, and for licensed nurses to oversee and document the effectiveness of such interventions. Despite these requirements, the prescribed contracture management program was not carried out, and the resident did not receive the ordered splinting interventions during the period reviewed.
Lack of Physician Orders and Documentation for Foley Catheter
Penalty
Summary
The facility failed to ensure that proper physician orders were in place for a resident with a Foley catheter. Upon review, it was found that the resident, who had multiple diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia, did not have a documented physician order specifying the diagnosis, Foley or balloon size, or instructions for catheter changes. The care plan referenced catheter use and related interventions, but the physician orders lacked essential details such as the reason for the catheter and specific directions for its management. Additionally, there was no documentation of recent catheter changes, despite the DON stating that a change had occurred about two weeks prior. The facility's own policy requires that residents with indwelling catheters receive appropriate care, including maintaining dignity and privacy, but the lack of clear physician orders and documentation did not meet these standards. The DON confirmed the absence of necessary orders and documentation, and acknowledged that not all residents with neuromuscular bladder dysfunction require a catheter, further highlighting the need for individualized and documented medical justification.
Failure to Implement and Monitor Dietary Interventions for Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when the facility failed to identify, implement, monitor, and modify appropriate interventions for a resident who experienced coughing during meals. The resident, who had a history of metabolic encephalopathy, protein-calorie malnutrition, muscle wasting, acute respiratory failure, and dementia, was observed coughing and with watery eyes while eating spaghetti, meatballs, and garlic toast in the dining room. Staff intervened by removing the plate, but the resident's family member reported ongoing concerns about the lack of assistance with eating and stated that the resident was supposed to be on a pureed diet. The facility did not address the family member's concerns, citing a lack of documentation from the hospital regarding the need for assistance. Review of the resident's records revealed multiple changes in diet orders, including regular, pureed, and mechanically soft diets, as well as recommendations for thickened liquids and supervision during meals. Despite these orders and the resident's severe cognitive impairment, there were instances where the resident was served inappropriate food items, such as garlic bread, which were not consistent with her prescribed diet. Staff interviews confirmed that residents on mechanically altered diets should not receive foods with crusts or hard textures, yet the dietary manager admitted to serving garlic bread to all residents due to a lack of bread sticks. The resident was also noted to be non-compliant with her diet, obtaining snacks from vending machines and other residents, and required education and supervision to prevent consumption of unsafe foods. Speech therapy and nursing documentation indicated ongoing issues with swallowing and coughing during meals, with recommendations for diet modifications and supervision. However, there was a lack of consistent follow-up, as the facility did not have a full-time speech therapist, and the results of a hospital-ordered swallow study were not obtained or reviewed. The care plan and progress notes highlighted the need for a mechanically altered diet and close monitoring, but these interventions were not reliably implemented or adjusted in response to the resident's changing needs and observed difficulties during meals.
Failure to Provide and Document Ordered Oxygen Therapy and Proper Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards and physician orders for two residents. One resident with COPD, hypertension, and anemia was observed multiple times with an oxygen concentrator set at levels inconsistent with the physician's order of 2 liters per minute via nasal cannula. Documentation in the Medication Administration Record was incomplete, with several shifts lacking evidence that the ordered oxygen therapy was provided. The resident's care plan required oxygen administration as ordered, but observations and staff interviews confirmed the prescribed settings were not consistently followed. Another resident receiving oxygen therapy was also observed with the concentrator set below the ordered 2 liters per minute on several occasions. The Treatment Administration Record showed multiple shifts where monitoring of oxygen therapy was not documented as required. The care plan for this resident included interventions to provide oxygen as ordered, but staff interviews and record reviews confirmed that these interventions were not consistently implemented. Additionally, the facility failed to ensure proper storage of respiratory equipment for two other residents. Nebulizer masks were observed left unbagged on bedside tables after use, contrary to facility policy requiring such equipment to be bagged when not in use. Staff interviews confirmed awareness of the policy, and facility procedures outlined the need for proper cleaning and storage of respiratory equipment, which was not followed in these instances.
Failure to Provide Behavioral Health Services and Documentation
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident with a complex medical and psychiatric history, including vascular dementia, mood and psychotic disturbances, and anxiety. Observations revealed the resident frequently yelled out and hit her leg, behaviors that were not addressed through behavioral health interventions. The resident was unable to communicate about her care, and her care plan identified ongoing behavioral issues such as screaming, banging, and agitation, with interventions to monitor and document behaviors and attempt to determine underlying causes. However, there were no physician orders for behavior monitoring, and no documentation of behaviors was found in the Treatment Administration Record or progress notes. Interviews with staff indicated uncertainty about the need to monitor or document the resident's behaviors, and the DON described the behaviors as a form of communication rather than behavioral health issues. Despite the facility's policy requiring person-centered behavioral health services and documentation, there was no evidence that the resident's behaviors were being consistently monitored, documented, or addressed through appropriate behavioral health care services.
Failure to Accurately Document Vital Signs, Medication Administration, and Catheter Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding documentation of vital signs, medication administration, and indwelling catheter care. For one resident, review of the Medication Administration Record (MAR) revealed repeated documentation of identical vital signs across multiple shifts and days, as well as missing entries for required vital sign monitoring on several shifts. Additionally, the MAR did not include blood pressure readings at the time of administration for a medication that required withholding if systolic blood pressure exceeded a certain threshold, and there were missed medication administration times. For another resident, documentation inconsistencies were found related to the presence and care of a Foley catheter. Although the resident's catheter was removed and not reinserted per physician orders, nursing staff continued to document catheter care and the use of a privacy bag for a drainage bag for several days after the catheter had been discontinued. This was despite multiple clinical notes indicating the resident no longer had a catheter and was incontinent of urine. Facility policy required that all documentation in the medical record be factual, objective, accurate, and complete, reflecting the actual experiences and care provided to the resident. However, staff documented care and observations that did not occur, including false entries for catheter care and vital signs, which was confirmed by the Director of Nursing, who acknowledged that such documentation was incorrect.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the resident representative following an accident involving a resident who had a history of repeated falls and multiple medical diagnoses, including urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, and difficulty walking. The resident experienced a fall in the early morning hours, as documented in the Change in Condition Evaluation, but the section for resident or representative notification was left blank. Review of progress notes also showed no documentation that the family was informed of the fall at the time it occurred. Subsequently, the resident was sent to the emergency room for treatment after expressing increased pain and being found to have a left hip fracture. The family was only notified about the fall and the transfer to the hospital several hours after the incident. During interviews, facility leadership confirmed that there was no documentation of family notification immediately following the fall, and acknowledged that the family should have been informed at that time.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 74 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winter Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Lake Rehabilitation Center | 1 mi | — | 0 | 0 |
| Oak Haven Rehab And Nursing Center | 2.3 mi | — | 4 | 0 |
| Winter Haven Health And Rehabilitation Center | 3 mi | — | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 3.6 mi | — | 4 | 2 |
| Life Care Center Of Winter Haven | 3.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.