Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record review, and the facility did not respond to grievances in a timely manner
for one (Resident #131) of 51 sampled residents.
Findings included:
Resident #131 was a [AGE] year old female admitted to the facility from an acute care hospital after
experiencing a fall at home. She was living independently prior to her fall. The Resident's Brief Interview for
Mental Status score was 15 which indicated intact cognition.
An interview with Resident #131, on 10/31/2022 at 9:43 a.m., revealed she filed a grievance with the Social
Worker on 10/19/2022 and the grievance was taken care of today, 10/31/22. Resident #131 stated the
grievance was about the frequency of her dressing changes and she was not receiving some of her psych
meds.
A follow up interview was conducted on 11/01/22 at 2:53 p.m. and Resident #131 stated, I filed a grievance
on the 19th [October 2022] and yesterday when you [surveyor] arrived they came and wanted me to sign
saying I agreed with what they wrote. The Social Worker made me feel like I had to sign it so I did.
An interview was conducted with the Social Worker on 11/02/22 at 1:48 p.m. She reviewed the October
grievance log. The log indicated on 10/19/22 Resident #131 filed a grievance about missing psych and pain
medications and on 10/31/22 filed another grievance about not receiving daily dressing changes. The
Social Worker stated they had five days to resolve grievances, so this one (10/31/22) was still in process.
The Social Worker said the psychiatry Advanced Practice Registered Nurse (APRN) was at the facility
yesterday,11/01/2022, and she would make sure to send a note for her to get seen. The Social worker did
not give a reason for the delay.
Resident #131 was interviewed in her room on 11/02/22 at 2:10 p.m. and stated, Since the grievance on
19th [October 2022], I haven't seen psych. I'm missing two bipolar meds. They were supposed to have
psych see me, but I haven't seen them.
On 11/03/22 at 10:05 a.m. the APRN was interviewed and stated she was aware of the resident's question
to restart meds. The APRN stated the resident was not receiving those meds in the hospital and she gave a
verbal order for a psych consult. Resident #131's medical record was reviewed with the APRN for a psych
consult order. The APRN confirmed there was no order in the medical record for a consult. The APRN was
able to show the Psychiatry APRN had conducted an initial evaluation of Resident
(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 7
Event ID:
105491
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0585
#131 on 10/13/22.
Level of Harm - Minimal harm
or potential for actual harm
The Unit Manager was interviewed on 11/03/22 at 11:02 a.m. Unit Manager stated the Psychiatry APRN
came twice a week. The Unit manager was unable to locate a more recent psychiatry progress note.
Residents Affected - Few
A review of the Grievance/Concern Report done on 11/03/22 at 8:33 a.m. confirmed Resident #131 filed a
grievance on 10/19/22. The form indicated the resident concern was resolved on 10/26/22 and showed:
Spoke with resident advised psych would see with next visit regarding meds. Meds were not on discharge
medication list provided to facility. Resident was seen by psychology. On 10/31/22 the document was
signed by Resident #131 and Social Worker indicating Resident #131 was satisfied with the resolution.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 2 of 7
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and interviews, the facility failed to implement the care plan related to
interventions to manage resident wounds for one (Resident #55) of two residents sampled for wounds.
Findings included:
Review of Resident #55's record revealed the resident was re-admitted to the facility on [DATE], with
diagnoses that included Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis
Following Cerebral Infraction Affecting Right Dominant Side and, Arterial fibrillation.
Observations on 11/03/22 at 8:23 a.m., revealed the resident lying in bed. He was noted to have a left foot
wound dressing and no Podus boot. Closer observation of the room revealed the Podus boot was lying in
the residents reclining chair by the window. In an interview with the resident at this time, he denied taking
the boot off and denied having the boot on during the night. In an interview with Staff B, Certified Nursing
Assistant (CNA) who entered the resident room with his meal tray, she reported she was assigned to the
resident and did not know why the boot was not on. She reported the night shift might have forgotten to put
it on.
During an interview on 11/03/22 at 8:24 a.m., Staff D, Licensed Practical Nurse (LPN) revealed the resident
should have the boot on while in bed to prevent any additional `skin breakdown.
Review of the care plan related to skin impairment dated 8/28/19 revealed an intervention to float heels
while in bed as tolerated.
Review of the Weekly pressure wound note dated 10/13/22 revealed a Wound Support Intervention that
included 3. Offloading boots.
Review of the Weekly pressure wound note dated 10/27/22 revealed a Wound Support Intervention that
included 3. Offloading boot(s)
Request was made for a policy related to implementation of the care plan, but was not provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 3 of 7
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interviews, the facility failed to ensure the administration of enteral nutrition
was completed according to physician orders and facility policy for one (Resident #88) of one resident
sampled for the administration of liquid nutrition via a percutaneous endoscopic gastrostomy (PEG).
Findings included:
An observation was conducted on 11/2/22 at 2:04 p.m. with Staff F, Licensed Practical Nurse (LPN) of the
administration of liquid nutrition for Resident #88. Staff F removed a 60 cubic centimeter (cc) syringe from
the package, picked up the end of the PEG where it lay near the side of the bed, inserted the syringe into
the tube, flushed the tube with 30 cc's of water, then inserted the end of nutrition tubing into the PEG, and
turned on pump. The pump was programmed to deliver the liquid nutrition at 75 milliliter (mL) per hour and
a water flush at 150 mL/hr. Staff F pulled back the residents blanket and observed the PEG's insertion site.
The staff member confirmed that checking the nutrition residual had been forgotten, usually checks.
Resident #88 was initially admitted on [DATE] and recently on 6/28/22. The admission Record included
diagnoses not limited to gastrostomy malfunction, tracheotomy status, and anoxic brain damage not
elsewhere classified.
A review of the Medication Review Report, identified an order dated 6/29/22 that instructed staff to Check
residual every shift and record quantity. If more than 100 cc's hold feeding for 1 hour and notify MD, every
shift. The report indicated this order had been discontinued. The report also indicated that staff were to
Check G-tube placement. Notify MD if dislodged, every shift for Tube management.
The October and November Medication Administration Records (MAR) included documentation that the
order to check and record the quantity of residual had been completed without the recording the amount of
Resident #88's residual. The documentation indicated that the order was written on 6/29/22 and
discontinued at 12:03 p.m. on 11/3/22.
The Medication Report included two physician orders dated 11/3/22 (the day after the observation) which
instructed staff as follows:
- Check residual at 2 p.m. prior to administration, one time a day.
- Check residual every shift if more that 100 cc's hold feeding for 1 hour and notify MD, every shift.
The care plan for Resident #88 identified the resident was at risk for complications associated with enteral
feedings due to nothing by mouth (NPO) status and received enteral feeding to meet nutritional and
hydration requirements, initiated 8/23/2019. The interventions related to the care plan included: Administer
enteral feeding and flushes as orders; observe for tolerance and check enteral feeding residuals as
ordered.
A review of Resident #88's progress notes dated 10/4 to 11/1/22 did not include any documentation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 4 of 7
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0693
of residual amounts.
Level of Harm - Minimal harm
or potential for actual harm
An interview was conducted on 11/3/22 at 9:22 a.m. with Staff F regarding Resident #88's enteral nutrition.
The staff member stated that the electronic record did not include an area to document residual.
Residents Affected - Few
On 11/3/22 at 11:49 a.m., the Director of Nursing (DON) reviewed Resident #88's physician order to check
and document residual and confirmed there was no area to record the amount. The Assistant DON stated
the order was from June and the DON replied missed it. The DON stated the expectation was to check for
residual prior to medications and starting nutrition and placement should be verified prior to administration.
The policy - Care and Treatment of Feeding Tubes, implemented 9/23/22, identified that It is a policy of this
facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to
prevent complications to the extent possible. The policy included the following explanations and guidelines:
- Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding
and its caloric value, volume, duration, mechanism of administration, and frequency of flush.
- The resident's plan of care will address the use of feeding tube, including strategies to prevent
complications.
- In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the
right location (e.g., stomach or small intestine, depending on the tube); a. Tube placement will be verified
before beginning a feeding and before administering medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 5 of 7
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility did not ensure the medication error rate was
below 5.00%. A total of twenty-eight medications were observed administered and four errors were
identified for three (Resident #13, #113 and #597) of four residents observed. These errors constituted a
medication error rate of 14.29 percent.
Residents Affected - Few
Findings included:
On 11/02/2022 at 8:56 a.m., an observation of medication administration with Staff D, Licensed Practical
Nurse, (LPN)-Agency, was conducted with Resident #597. Staff D, LPN was observed administering the
following medication:
-Oxcarbazepine Extended Release (ER) Tablet (Oxtellar XR), 150 Milligrams Orally twice a day for
diagnosis of mood disorder.
Staff D placed the medications in a clear envelop and then crushed the medications with a pill crusher. The
medication had a pharmacy label instruction which indicated to not Chew or crush the medication.
A record review of Resident #597's active physician orders dated 10/26/2022 read May crush medications
and combine unless contradicted.
A facility provided policy titled, Medication Administration, date 09/07/2022, Page 01 and 02 reads under
Policy Explanation and Compliance Guidelines:
14. Administer medication as ordered in accordance with manufacturer specifications.
c. Crush medications as ordered. Do not crush medications with do not crush instructions.
Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not
all-inclusive.
Do Not Crush Medications: Slow Release
On 11/02/2022 at 9:26 a.m., an observation of medication administration with Staff D, (LPN)-Agency, was
conducted with Resident #13. Staff D, (LPN)-Agency was observed administering Breo-Ellipta 100-25
Micrograms (MCG)- Aerosol Powder, Breath Activated one Puff by mouth one time a day for Shortness of
Breath (SOB). The pharmacy label read the following highlighted in yellow rinse mouth after use. Resident
#13 was observed swallowing the water that Staff D, (LPN)-Agency gave him, and did not rinse his mouth
after one puff of the medication. Staff D, (LPN) did not wait five minutes, prior to administering the other
aerosol medication of Combivent Respimat Aerosol Solution 20-100 MCG/ACT. During an immediate
interview with Resident #13, he confirmed he did not rinse his mouth, and did swallow the medication.
On 11/02/2022 at 09:30 a.m., an observation of medication administration with Staff E, (LPN), was
conducted with Resident #113. Staff E, LPN was observed administering the following medication:
-Combivent Respimat Aerosol Solution 20-100 MCG/ACT 2 puff inhale orally two times a day for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 6 of 7
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
105491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare Gandy
4610 S Manhattan Ave
Tampa, FL 33611
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 0759
diagnosis of SOB
Level of Harm - Minimal harm
or potential for actual harm
-Flovent HFA Aerosol 220 MCG/ACT (Fluticasone Propionate HFA)- 2 puff inhale orally two times a day for
diagnosis of asthma.
Residents Affected - Few
The label on medication Flovent HFA Aerosol 220 MCG/ACT read
Rinse mouth/gargle after use, wait one minute between puffs, and five minutes with different inhalers.
During the observation, Staff E, (LPN) did not follow the pharmacy label instructions, to wait one minute
between puffs, and did not have Resident #113 gargle, and rinse their mouth after they were given the
medication.
Staff E, (LPN) was immediately interviewed. She looked at the pharmacy labels of the Flovent HFA Aerosol
220 MCG/ACT medication and revealed that she did not know she was supposed to follow the directions on
the pharmacy label. She further indicated she would follow the pharmacy label instructions to wait five
minutes in between administering both medications, and to tell Resident #113, to gargle and rinse their
mouth, the next time she administered the medications to them.
On 11/02/22 at 10:11 a.m., an interview was conducted with Staff D (LPN), -Agency related to the Resident
#13 not rinsing his mouth after inhalation of the medication (as per directed on the pharmacy label). Staff D
(LPN) stated I do not remember; I will give him education. (Photographic Evidence Obtained.)
An interview was conducted with the Director of Nursing (DON), on 11/02/2022 at 12:01 p.m. During the
interview the DON was notified of observations made during medication administration with Staff D
(LPN-Agency and Staff E (LPN). The DON stated, Extended Release (ER) medications should not be
crushed, we will get a alternative, and all staff should be following the instructions on the pharmacy labels
of medications.
On 11/02/2022 at 04:58 p.m., a telephone interview was conducted with Senior Care Pharmacy Consultant.
The Pharmacy consultant was informed of the observations made of both Staff D (LPN)-Agency and Staff
E, (LPN). He stated, It's pretty simple, give the medications in the correct way, as per manufacturer's
instructions.
A facility provided policy titled, Oral Inhalation Administration, with revision date 08-2020, Pages 156 and
157, revealed under Policy: Medications will be administered in a safe and effective manner. Procedures:
Sequencing of Inhaler Medications7. A wait time of 5 minutes (or manufacturer's recommendation) should be observed between inhalers of
different types.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105491
If continuation sheet
Page 7 of 7
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Back to topCitations
6 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.
- 0271GeneralS&S Dpotential for harm
Have exits that are accessible at all times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2022 survey of Vivo Healthcare Gandy?
This was a inspection survey of Vivo Healthcare Gandy on November 3, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Vivo Healthcare Gandy on November 3, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have exits that are accessible at all times."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.