Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Let each resident or the resident's legal representative access or purchase copies of all the resident's
records.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to provide one (Resident #3) of one family-requested medical
record in a timely manner.
Findings included:
Review of Resident #3's medical record showed the resident was admitted on [DATE] with diagnoses not
limited to unspecified Alzheimer's disease, unspecified peripheral vascular disease, atherosclerotic heart
disease of native coronary artery without angina pectoris, and unspecified edema.
An interview was conducted on 6/4/23 at 12:30 p.m. with the Medical Records Director (MRD). The MRD
reported only one family member had requested medical records and the request had been made on July
28, 2023. The staff member reported sending the attorneys Resident #3's face sheet and death certificate
and did not get a response from them for two or three months. The MRD reported speaking to the Business
Office Manager about general matters and had been informed the attorneys had not been getting paid (the
facility was sold at the end of June 2023). She stated the new company [name of company] had told her to
hold off on legal cases, hold off on sending charts, and to follow company procedures, which was to contact
company attorneys. The MRD stated at that time the facility did not have attorneys. The MRD admitted to
speaking with Resident #3's family member regarding the medical records but she did not want to just give
the family member the records and had informed the family she was waiting for the attorneys. The MRD
stated the family member had informed her that the family attorney would request the records but had not
heard from the attorney of the family since October 2023. The MRD reviewed the Authorization to Release
Protected Health Information, dated July 28, 2023, confirming the request was made approximately 11
months ago.
During the continued interview with the MRD on 6/4/23 at 1:05 p.m., the staff member reported the facility
did have attorneys and there was no outstanding requests for records. She reported there was one other
request from a resident that was requesting from another facility and all others were attorney requests.
Review of the Authorization to Release Protected Health Information signed by Resident #3's Power of
Attorney on July 28, 2023, showed the family member had requested clinical summaries, lab and
diagnostics, and entire medical record.
Review of policy, Release of Information, revised November 2009, revealed Our facility maintains the
confidentiality of each resident's personal and protected health information. The policy interpretation and
implementation showed:
(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 5
Event ID:
105354
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
105354
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Lakeland
1919 Lakeland Hills Blvd
Lakeland, FL 33805
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)
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. All information contained in the resident's medical record is confidential and may only be released by the
written consent of the resident or his/her legal representative(sponsor), consistent with state laws and
regulations.
7. Closed or thinned medical records are maintained in the Medical Records Department and are available
only to authorized personnel. Authorized personnel include, but are not necessarily limited to:
a. Nursing Personnel;
b. Physicians;
c. Consultants;
d. Support Services (i.e., Dietary, Activities, Social, etc.);
e. Administration
f. Government Agencies; and/or
g. Resident/Representative (sponsor).
8. The resident may initiate a request to release such information contained in his/her records and charts to
anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated
request from the resident or representative (sponsor).
9. A resident may have access to his or her records within (blank) hours (excluding weekends or holidays)
of the resident's written or oral request.
10. A resident may obtain photocopies of his or her records by providing the facility with at least forty-eight
(48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charted for
copying services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105354
If continuation sheet
Page 2 of 5
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
105354
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Lakeland
1919 Lakeland Hills Blvd
Lakeland, FL 33805
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)
F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, record reviews, and interviews, the facility failed to ensure physician-ordered
laboratory tests were completed for one (Resident #6) of three residents sampled for diagnostic laboratory
testing.
Residents Affected - Few
Findings included:
An observation and interview were conducted with Resident #6 on 6/4/24 at 2:07 p.m. The resident stated
the provider had informed him that blood work was going to be done but it had not been done. The resident
reported being told about the laboratory testing a couple weeks ago and again last week.
Review of a provider note, dated 5/24/24, revealed the plan for Resident #6 included to obtain a weekly
Creatinine level, status post renal transplant, and to avoid nephrotoxic agents including Diuretics.
Review of a provider note, dated 5/30/24, showed the resident was seen to follow up on Physical
Therapy/Occupational Therapy and ultrasound results. The provider's plan was for Vitamin B12/Folate
Levels with next blood draw.
Review of a provider note, dated 5/31/24, revealed Resident #6 was seen by the provider while sitting in a
wheelchair and complained of bilateral lower extremity (BLE) edema. The Advanced Practitioner Registered
Nurse (APRN) documented the plan was to check weekly Creatinine - status post renal transplant, avoid
Nephrotoxic agents which listed certain classes of medications including Diuretics, and to recheck Basic
Metabolic Panel (BMP) on Monday (6/3/24).
Review of discontinued laboratory physician orders showed the following orders:
Basic Metabolic Panel (BMP) with glomerular filtration rate (GFR) every night shift every Monday for status
post (s/p) renal transplant, ordered 5/24/24 and to start on 5/27/24.
Complete Blood Count (CBC) with differential (diff), Complete Metabolic Panel (CMP), Magnesium (Mag)
every night shift for baseline for 1 day, ordered and to start on 5/27 and to end on 5/28/24.
CBC, BMP, MAG 6/3 every night shift for repeat labs for 2 days, ordered 5/31, start 6/3/24 and end 6/5/24.
Review of Resident #6's available laboratory testing results showed a CBC with diff and a CMP was
collected 5/23/24 at 7:00 a.m. and reported on 5/23/24 at 6:02 p.m., and See Attached STAT Results
Below, collected on 6/4/24 at 7:20 p.m. and reported at 2:37 a.m. on 6/5/24. The results tab of the resident's
medical record did not contain any other laboratory results.
Review of Resident #6's laboratory results and physician orders showed the BMP with GFR ordered to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105354
If continuation sheet
Page 3 of 5
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
105354
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Lakeland
1919 Lakeland Hills Blvd
Lakeland, FL 33805
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)
F 0770
Level of Harm - Minimal harm
or potential for actual harm
be done on 5/27/24 was not completed, the CBC with diff, CMP, and Mag ordered to be obtained on
5/27/24 was not completed (per Treatment Administration Record (TAR) the order was discontinued while
pending confirmation), and the CBC, BMP, and MAG ordered on 5/31 to be drawn on 6/3/24 was not
completed. Review of the Laboratory orders did not show an order for weekly Creatinine draws or for the
planned (note 5/30/24) Vitamin B12/Folate laboratory testing with the next blood draw.
Residents Affected - Few
Review of Resident #6's May TAR revealed an order for CBC with diff, CMP, and MAG discontinued while
pending confirmation on 5/27/24 and a CBC and CMP was drawn on 5/22/24. The review did not show any
other laboratory testing orders. The resident's May Medication Administration Record (MAR) did not include
any laboratory tests.
An interview was conducted with Staff A, Registered Nurse (RN) on 6/4/24 at 2:16 p.m., the staff member
reported doesn't typically review doctor notes, if there were orders some of the providers put them in
themselves. Staff A demonstrated when putting a laboratory order in, have to use drop down box for
Labs/TAR so the order will show up on the TAR and if not in that dropdown box it won't pop up. The staff
member reviewed the order for BMP with GFR, written on 5/24 to start on 5/27/24. Staff A confirmed the lab
should have been drawn Sunday into Monday morning. The staff member stated usually the physician will
communicate with the nurses if labs were ordered or needed to be ordered.
Review for Resident #6's order dated 5/24/24 showed a BMP with GFR was ordered every night shift every
Monday for s/p renal transplant. The order type was LAB
Review of Resident #6's June TAR showed 2 laboratory orders:
STAT 6/4/24 at 7:40 p.m., CBC, BMP and Magnesium. Showed it was obtained on 6/4/24 at 9:47 p.m.
LABS - One week CMP, (Vitamin) B12, Folate one time only for monitoring until 6/12/24
An interview was conducted with Staff B, Licensed Practical Nurse (LPN/Unit Manager (UM) on 6/5/24 at
10:42 a.m. Staff B reported she confirmed orders by clicking on the pending or pending confirmation order
and reviewed it just to see if written correctly. Staff B stated this was the first time (newly hired) she had to
go behind the providers to confirm. Staff B reported not realizing there was a LABS/TAR and LABS
(dropdown box) in a different area and was educated on it today. Staff B stated it was expected that labs
showed up on the TAR so nurses could check off on them. Staff B said she did not review providers notes
that were put in the computer (providers written) or downloaded in the chart. She did not know who
reviewed physician notes and they (physician's) could upload notes through their system. Staff B stated
orders should be ordered according to their plan (in notes).
During an interview on 6/5/24 at 11:13 a.m., the Interim Director of Nursing (DON) stated the previous DON
had reviewed physician notes, but she had not had a chance to review them. The staff member stated as a
Unit Manager she had reviewed notes uploaded but it was not something she did every day. The Interim
DON stated some (providers) put in orders themselves, it would pop-up to do a confirmation, and she
looked at the order to make sure it was put in correctly. The staff member stated a Standard LAB would not
populate for staff to see (on TAR), it had to go under LAB/TAR. The DON reported educating the APRN and
NP regarding putting in orders correctly. The DON stated the expectation was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105354
If continuation sheet
Page 4 of 5
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
105354
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Lakeland
1919 Lakeland Hills Blvd
Lakeland, FL 33805
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)
F 0770
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
for orders to be put in correctly and when the providers were at facility to let staff know of all orders. The
reason for confirming orders was to make sure they were put in correctly.
Review of the policy - Laboratory Services and Reporting, implemented 9/1/23, showed The facility must
provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner,
or clinical nurse specialist in accordance with state law. The compliance guidelines revealed:
1. The facility must provide or obtain laboratory services to meet the needs of its residents.
2. The facility is responsible for the timeliness of the services
7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist
of laboratory results that fall outside the clinical reference range.
Review of the policy - Provision of Physician-Ordered Services, implemented on 9/1/23, showed The
purpose of this policy is to provide a reliable process for the proper and consistent provision of physician
ordered services according to professional standards of quality. The definition of Professional Standards of
Quality means that care and services are provided according to accepted standards of clinical practice.
Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or
setting. The compliance guidelines revealed:
2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory,
radiology, (and) consultations) to the appropriate entity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105354
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F573 - The resident has the right to access personal and medical records pertaining
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
FAQ · About this visit
Common questions about this visit
What happened during the June 5, 2024 survey of VIVO HEALTHCARE LAKELAND?
This was a inspection survey of VIVO HEALTHCARE LAKELAND on June 5, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VIVO HEALTHCARE LAKELAND on June 5, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Let each resident or the resident's legal representative access or purchase copies of all the resident's records."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.