Inspection·February 13, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document the occurrence of falls in the medical record for two (#3 and #4) of three residents sampled for documentation related to falls. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and dementia. A diagnosis of traumatic subdural hemorrhage without loss of consciousness was added on 12/23/2023. Resident #3 was discharged from the facility on 1/15/2024. A review of the facility's incident log for December 2023 revealed Resident #3 had an unwitnessed fall on 12/19/2023 at 4:34 PM. A review of Resident #3's progress notes dated 12/19/2023 at 9:00 PM revealed Resident #3 was transferred to the hospital and was diagnosed with a subdural hematoma. A review of Resident #3's progress notes did not reveal documentation related to Resident #3's fall on 12/19/2023 at 4:34 PM. Further review of Resident #3's medical record did not reveal documentation or assessments related to Resident #3's fall on 12/19/2023 at 4:34 PM. A review of a facility report dated 12/19/2023 at 4:34 PM revealed Resident #3 was observed sitting on the floor next to the toilet in his bathroom after a fall. The report also revealed Resident #3 had a small laceration to his nose and a small scraped area on his forehead with a yellow colored bruise on the left side of his nose. Resident #3 was assessed by the facility's Director of Nursing (DON) and sent to the hospital for evaluation. The facility report was not part of Resident #3's medical record. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and atrial fibrillation. A review of the facility's incident log for February 2024 revealed Resident #4 had an unwitnessed fall on 2/12/2024 at 2:13 PM. A review of Resident #4's progress notes did not reveal documentation related to Resident #4's fall on 2/12/2024 at 2:13 PM. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105352 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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)