Inspection Reports for Life Care Center of Winter Haven
1510 Cypress Gardens Blvd, Winter Haven, FL 33884, United States, FL, 33884
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 10
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, grievance handling, PASARR screening, wound care, foot care, laboratory services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete PASARR screenings, medication administration errors with a 42.42% error rate, failure to provide appropriate wound and foot care, failure to provide timely laboratory testing, failure to provide timely transfer notification, failure to file grievances, and failure to clean medical equipment between residents.
Deficiencies (10)
Failed to ensure residents were provided dining services and resident care with dignity for four residents.
Failed to ensure two residents were assessed for self-administration of medications and failed to ensure physician orders for medications observed on over-bed table.
Failed to file a grievance related to missing clothes for one resident.
Failed to provide written notification to the resident and resident representative prior to an emergency transfer for one resident.
Failed to complete accurate PASARR screening for eleven residents.
Failed to provide wound care in accordance with professional standards and physician orders for one resident.
Failed to provide proper foot care and treatment to maintain good foot health for three residents.
Medication error rate was 42.42% with fourteen errors identified out of thirty-three medication administration opportunities for six residents.
Failed to obtain physician ordered laboratory testing for one resident.
Failed to ensure direct care equipment was cleaned between two residents during medication administration.
Report Facts
Medication error rate: 42.42
Medication administration opportunities observed: 33
Medication errors identified: 14
Residents sampled for PASARR screening accuracy: 33
Residents with inaccurate PASARR screening: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Named in dining assistance deficiency and foot care deficiency. |
| Staff B | Licensed Practical Nurse | Named in dining assistance deficiency and medication administration deficiency. |
| Staff F | Licensed Practical Nurse/Unit Manager | Named in dining assistance deficiency and foot care deficiency. |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding dining assistance, grievance handling, medication administration, and laboratory testing. |
| Staff A | Licensed Practical Nurse/Unit Manager | Named in dining assistance deficiency, medication administration, and foot care deficiency. |
| Staff Q | Master Social Worker | Named in dining assistance deficiency and PASARR screening deficiency. |
| Staff E | Director of Housekeeping | Named in grievance handling deficiency. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding grievance handling and transfer notification. |
| Staff H | Registered Nurse | Named in wound care deficiency. |
| Staff G | Licensed Practical Nurse, Wound Care Nurse | Named in wound care deficiency. |
| Staff C | Registered Nurse | Named in foot care deficiency. |
| Staff L | Certified Nursing Assistant | Named in foot care deficiency. |
| Staff M | Registered Nurse | Named in medication administration deficiency. |
| Staff N | Licensed Practical Nurse | Named in medication administration deficiency and infection control deficiency. |
| Staff O | Registered Nurse | Named in medication administration deficiency. |
| Staff P | Licensed Practical Nurse | Named in medication administration deficiency. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, PASARR screening, skin care, respiratory care, psychotropic medication use, and medication administration.
Findings
The facility was found deficient in maintaining resident dignity related to catheter privacy, completing PASARR Level II assessments for residents with new mental health diagnoses, providing appropriate skin assessments and treatments, ensuring respiratory equipment was stored and maintained properly, monitoring behavioral and side effects of psychotropic medications, and maintaining medication error rates below 5%.
Deficiencies (6)
Failure to maintain resident dignity related to catheter exposure to the public for two residents.
Failure to complete PASARR Level II assessments for six residents with new qualifying mental health diagnoses.
Failure to provide appropriate skin assessments and treatments for two residents with skin impairments.
Failure to ensure respiratory equipment was stored in a sanitary manner for six residents.
Failure to ensure behavioral and side effect monitoring related to psychotropic medication use for one resident.
Medication error rate exceeded 5% with two errors observed in medication administration for one resident.
Report Facts
Medication opportunities observed: 29
Medication errors identified: 2
Medication error rate: 6.9
Residents sampled for PASARR Level II: 7
Residents not assessed for PASARR Level II: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Confirmed catheter privacy cover should be used for Resident #133. |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed catheter privacy cover should be used for Resident #133. |
| Staff C | Licensed Practical Nurse (LPN) Unit Manager | Observed catheter exposure for Resident #103 and Resident #49's skin condition; confirmed respiratory equipment storage issues. |
| Director of Nursing (DON) | Director of Nursing | Confirmed catheter privacy expectations, PASARR review process, respiratory equipment protocols, and medication administration standards. |
| Staff D | Licensed Practical Nurse (LPN) | Administered medication in error to Resident #107 and did not instruct on inhaler use. |
| Staff E | Licensed Practical Nurse (LPN) | Confirmed lack of behavioral and side effect monitoring orders for Resident #32. |
| Social Services Director (SSD) | Social Services Director | Reviewed PASARRs and confirmed missing assessments for residents with new diagnoses. |
| Psychiatrist | Facility Psychiatrist | Confirmed diagnoses and PASARR requirements for Resident #40. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 12, 2021
Visit Reason
The inspection was conducted based on complaints and observations related to care planning, medication administration, psychotropic medication monitoring, medication error rates, drug storage, food safety, and quality assurance practices at Life Care Center of Winter Haven.
Complaint Details
The complaint investigation revealed failures in care planning, medication administration, psychotropic medication monitoring, medication error rates, drug storage, food safety, and quality assurance related to behavior monitoring for residents on psychotropic medications.
Findings
The facility failed to implement care planned interventions for residents, did not adequately monitor behaviors and side effects related to psychotropic medications, had a medication error rate exceeding 5%, improperly stored drugs and biologicals, failed to store and label food properly, and did not effectively implement quality assurance plans related to behavior monitoring for residents on psychotropic medications.
Deficiencies (6)
Failed to implement a care planned intervention related to the use of heel protectors for one resident (#15).
Did not monitor specific behaviors or side effects of psychotropic medications for residents (#84 and #115).
Medication error rate was 14.29%, exceeding the 5% threshold, with errors observed in medication administration for three residents (#3, #44, and #37).
Failed to maintain drugs and biologicals in accordance with professional principles, including unlocked treatment cart, undated opened medications, and improper storage of insulin pens and comfort kits.
Failed to store food in accordance with professional standards, including undated pre-prepped desserts, undated sandwich and fruit plate, personal water bottles stored in cooler, and measuring scoops stored inside dry goods containers.
Failed to implement an effective quality assurance plan related to behavior monitoring associated with psychotropic medication use for three residents (#6, #5, and #4).
Report Facts
Medication error rate: 14.29
Residents sampled for medication errors: 5
Residents affected by deficiencies: 47
Residents sampled for psychotropic medication monitoring: 5
Residents sampled for behavior monitoring quality assurance: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed medication administration and interviewed regarding side effect monitoring. |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding behavior documentation and medication cart observations. |
| Staff C | Licensed Practical Nurse (LPN) | Observed medication administration and interviewed regarding care plan and medication storage. |
| Staff D | Unit Manager (UM) | Observed behavior monitoring documentation and medication storage. |
| Staff E | Licensed Practical Nurse (LPN) | Observed medication administration and treatment cart status. |
| Staff F | Licensed Practical Nurse (LPN) | Observed medication administration. |
| Staff G | Licensed Practical Nurse (LPN) | Observed medication cart and medication storage. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plans, medication administration, insulin pen priming, and quality assurance. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding side effect monitoring documentation. |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication storage and behavior monitoring. |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed and observed food storage and kitchen practices. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding quality assurance and deficiency status. |
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