Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vivo Healthcare Sebring during CMS and state inspections, most recent first.
Surveyors found multiple food safety issues in the walk-in cooler, including unwrapped and undated butter, spoiled green bell peppers with visible bio-growth, cabbage with extensive black spots, and an open box of turkey franks with exposed product. A box of bananas on a metal rack was surrounded by small black winged pests, and the bananas were overly soft with split skins exposing the flesh. In interviews, the Dietary Manager described practices of dating items on receipt and opening but not using end dates for refrigerated or frozen foods, and acknowledged that all open items should be labeled, dated, and discarded after three days, with no uncovered storage except for produce. The NHA stated that produce should be discarded when it shows signs of spoilage and that refrigerated items should have both open and expiration dates, which contrasted with the conditions observed. Review of the facility’s food safety policy confirmed requirements for proper labeling, dating, covering, and monitoring of refrigerated foods that were not met in these instances.
A facility failed to maintain a medication administration error rate below five percent, resulting in a 33.33% error rate. An LPN administered medications late to a resident without notifying the physician and made multiple errors with another resident, including administering the wrong form of aspirin and failing to administer paroxetine hydrochloride. The facility's policy requires timely administration and physician notification for late medications, which was not followed.
The facility failed to revise PASARR Level I for three residents to include accurate diagnoses recognized at the time of admission and later identified. The discrepancies were confirmed by the SSD and DON, indicating a failure in the PASARR process and whole house audit.
The facility failed to ensure proper behavior monitoring for psychotropic medication for five residents and did not appropriately monitor the side effects for one resident. Staff interviews confirmed the lack of proper monitoring and documentation for these medications.
The facility failed to maintain a clean, safe, and sanitary environment, with issues such as a dirty wheelchair, improperly stored personal care items, and maintenance problems in resident rooms and shower areas. Interviews revealed that daily cleaning and room rounds were not effectively executed, and housekeeping staff were not notified of the issues.
The facility failed to assess two residents for self-administration of medications and ensure safe storage. One resident had unauthorized medications at the bedside, and another had pain relief patches and a roll-on pain reliever without proper orders or assessment. The care plans did not reflect their ability to self-administer medications.
A resident reported not receiving the correct size pull-ups for two weeks, despite informing staff. The facility's care plan and Kardex lacked specific size information, leading to confusion among staff. Interviews and observations confirmed that the facility had an adequate supply of medium pull-ups, but the resident was not provided with them.
The facility failed to develop and implement a care plan for a resident's respiratory needs, specifically the use of a CPAP machine. The resident reported that staff did not clean the equipment, and the care plan did not address the resident's respiratory status or use of respiratory equipment, which was confirmed by staff.
The facility failed to update the care plan for a resident with end-stage renal disease, resulting in inconsistencies in the dialysis schedule and transportation arrangements. The care plan showed outdated times, while the actual schedule had changed, and staff confirmed the oversight.
The facility failed to assess and provide appropriate wound care for two residents with non-pressure related skin conditions. One resident had undated and unchanged dressings on both ankles, with inconsistencies in documentation and missed treatments. Another resident had an undated dressing on the inner left elbow with delayed wound care orders and notifications. The facility did not follow its policies on wound treatment management and change in condition, leading to inadequate care and documentation.
The facility failed to implement a pharmacy recommendation for a resident with mood disorders. The DON agreed to add an order to monitor behaviors related to Seroquel use but did not follow through.
The facility failed to monitor side effects for a resident related to diuretic therapy and pain medication. Despite having a care plan that included interventions for pain management and monitoring for side effects, there was no documentation of such monitoring. A Licensed Practical Nurse/Unit Manager confirmed the absence of monitoring, acknowledging that it should have been in place.
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. Errors included late administration of medications and incorrect dosages given to two residents, contrary to physician orders and facility policy.
The facility failed to adhere to transmission-based precautions for a resident with C. diff and did not follow proper procedures for administering eye drops to another resident. A nurse entered a resident's room without PPE, and an LPN administered eye drops without wearing gloves, both actions contrary to the facility's infection control policies.
Improper Food Storage, Labeling, and Spoilage in Walk-In Cooler
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices in the walk-in cooler, where food was not stored, labeled, or discarded in accordance with professional standards and the facility’s own food safety policy. During an observation of the walk-in cooler, surveyors found an open box of individually wrapped butter with butter smeared on the box, at least two individual butter blocks unwrapped and exposed, and no dates or labels on the box or the individual portions. A produce box containing approximately a dozen green bell peppers was observed with black circles on the surface and fuzzy black and white bio-growth, and two peppers with a fuzzy white blue/green substance. Another produce box contained approximately 10 heads of cabbage with black spots all over the circumference of each head. An open box of turkey franks was also observed with the franks exposed. In the same cooler area, a metal rack held a box of bananas around which small black winged pests were flying. The bananas were soft to the touch, left indents when pressed, and several had split skins exposing the flesh. In interviews, the Dietary Manager explained that staff check dates when putting away stock and conduct a weekly walk-through for outdated items, adding a received date and an open date but no end date for refrigerated or frozen items, and stated that all open food items should be labeled and dated when opened and discarded three days after opening, and that no items should be stored uncovered except produce. The Nursing Home Administrator stated that produce should be discarded when it shows signs of going bad and that items in the refrigerator should have an open date and an expiration date. Review of the facility’s food safety policy showed requirements for labeling, dating, monitoring refrigerated foods, and keeping foods covered or in tight containers, which were not followed as evidenced by the observed conditions in the walk-in cooler.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a rate of 33.33% during the survey. This was observed through twelve medication administration opportunities, where four errors were identified involving two residents. Resident #4 was administered levetiracetam and metoprolol tartrate late without prior notification to the resident or their physician, which is against the facility's policy. Resident #5 experienced multiple medication administration errors. The LPN administered aspirin in a chewable form instead of the prescribed delayed-release form, and failed to administer paroxetine hydrochloride, despite signing it off as given in the electronic medication administration record (eMAR). Additionally, the LPN administered magnesium oxide after initially omitting it, correcting the error only after noticing it in the eMAR. The LPN was unaware of the need to notify the physician before administering medications late. Interviews with the LPN and the Director of Nursing (DON) revealed a lack of adherence to the facility's medication administration policy, which requires medications to be administered within an hour of the scheduled time and physician notification for late administration. The DON confirmed that staff are educated on the rights of medication administration, but the LPN's actions did not align with these standards, contributing to the high error rate observed.
Failure to Revise PASARR Level I for Accurate Diagnoses
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for three residents was revised for accuracy to include diagnoses recognized at the time of admission and later identified. Resident #63's PASARR Level I, completed on 4/16/24, did not include the diagnoses of anxiety and depression, despite these being documented in the resident's medical record and active orders. The Social Services Director (SSD) and Director of Nursing (DON) confirmed that the PASARR process was not followed correctly, and a whole house audit was not effective in identifying this discrepancy. Resident #56's PASARR Level I, dated 7/30/23, did not include the diagnosis of substance abuse, and there was no revised PASARR Level I for the new diagnosis of persistent mood disorder. The SSD confirmed that the PASARR should have been updated to reflect these diagnoses. The resident's medical record and active orders indicated the presence of these conditions, but the PASARR documentation was not accurate. Resident #30's PASARR, dated 2/2/24, did not accurately reflect the resident's diagnoses, including epilepsy, traumatic brain injury, and anxiety disorder. The care plan for Resident #30 included multiple diagnoses and conditions that were not documented in the PASARR. The facility's policy on coordinating assessments with the PASARR program was not followed, leading to incomplete and inaccurate PASARR documentation for the residents involved.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure proper behavior monitoring for psychotropic medication for five residents and did not appropriately monitor the side effects for one resident. Resident #56, who had diagnoses including generalized anxiety disorder and persistent mood disorder, was not monitored for behavior related to antidepressant medication from 4/23/24 to 5/18/24. Additionally, the side effect monitoring for antianxiety medication was documented with check marks instead of the required numbers corresponding to specific side effects. Staff interviews confirmed the lack of proper monitoring and documentation for Resident #56's medications. Resident #59, diagnosed with major depressive disorder, was observed to be in bed most of the time and had no behavior monitoring for the antidepressant medication Trazodone. Staff confirmed that there was no order for behavior monitoring and that excessive sleeping could be a behavior related to the medication. Similarly, Resident #63, who had severe cognitive impairment and was taking Mirtazapine for depression, did not have an order for behavior monitoring, which was confirmed by staff. Resident #65, with diagnoses including major depressive disorder and other specified persistent mood disorders, had multiple psychotropic medications prescribed but lacked proper behavior monitoring documentation. The TAR for behavior monitoring showed check marks without corresponding behavior codes. Lastly, Resident #32, who was taking Mirtazapine for depression, had incomplete behavior monitoring documentation on the MAR. The facility's policy on the use of psychotropic medication emphasized the need for monitoring and documentation, which was not adhered to in these cases.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, and sanitary environment for residents on the B Wing and in two shower rooms. Observations revealed a wheelchair with a pink substance and ripped armrests, personal care items improperly stored in resident rooms, and various maintenance issues such as a cracked ceiling light cover and black bio growth in the shower room. Additionally, the 100-hall shower room had personal items left out, and a resident reported being unable to use a topical pain reliever due to a missing spray top. Interviews with the Nursing Home Administrator and the Housekeeping and Laundry Director indicated that daily room rounds and cleaning were expected but not effectively executed. The Housekeeping and Laundry Director confirmed that housekeeping staff were not notified of the issues observed, and CNAs were supposed to keep personal items bagged. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the numerous cleanliness and safety issues found during the survey.
Failure to Assess and Ensure Safe Storage of Self-Administered Medications
Penalty
Summary
The facility failed to assess two residents for the self-administration of medications and to ensure the self-administered medications were safely stored. Resident #73 was found with an allergy nasal spray bottle, three vials of unknown eye drops, and a medication bottle on the bedside dresser. The resident did not have an order for the nasal spray and was only allowed to keep eye drops at the bedside as per the order received on 5/18/24. The Medication Self-Administration Safety Screen for Resident #73 did not include the nasal spray, and the resident's care plan did not reflect the ability to self-administer medications. Staff E, LPN/UM, acknowledged that the screening should have included all medications and that the resident should have been care planned for self-administration. Resident #178 was observed with an unopened box of pain relief topical patches, an opened roll-on pain reliever, and a tube of honey gel within reach. The resident admitted to using the roll-on pain reliever and stated that the family member brought the patches. The facility did not have an order for these medications, and the resident's care plan did not reflect the ability to self-administer pain medication. Staff E, LPN/UM, reported that Resident #178 should have been screened for self-administration and expressed doubt about the resident's capability to self-administer due to the need for staff assistance. The facility's policy on Resident Self-Administration of Medication requires an interdisciplinary team to determine if self-administration is clinically appropriate and to document the resident's preference. The policy also mandates secure storage of medications and regular assessments. Both residents were not properly assessed, and their care plans did not reflect their ability to self-administer medications, leading to the deficiency noted in the report.
Failure to Provide Correct Size Incontinent Supplies
Penalty
Summary
The facility failed to ensure reasonable accommodations were made for a resident who required medium-sized pull-ups. The resident, who was cognitively intact and independent in toileting, reported that she had been unable to obtain the correct size pull-ups for two weeks and was instead given small youth pull-ups, which were too tight and uncomfortable. Despite informing staff members, the issue was not resolved. The resident's care plan and Kardex did not specify the size of the disposable briefs she required, leading to confusion among staff members about her needs. Interviews with staff revealed that there was no consistent system for tracking the sizes of briefs or pull-ups needed by residents. The Central Supply staff member responsible for measuring residents and stocking supplies confirmed that the resident required medium pull-ups but was unaware of her current need. The Director of Nursing acknowledged that the Kardex did not provide the necessary size information and was unaware of the resident's request for medium pull-ups. Observations confirmed that the facility had an adequate supply of medium pull-ups, but the resident was not provided with them.
Failure to Develop and Implement Care Plan for Respiratory Needs
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's respiratory needs, specifically the use of a CPAP machine. The resident was observed with the CPAP machine and its tubing and cannula lying on top of it, and the resident reported that staff did not clean the equipment and that she would clean it herself upon discharge. The resident's physician orders included the use of BiPAP and CPAP machines but did not include instructions for cleaning the equipment. Additionally, the resident's care plan did not address her respiratory status or the use of respiratory equipment, which was confirmed by the staff during interviews. The MDS Coordinator acknowledged that there should have been a care plan for the resident's use of CPAP and that a care plan had been initiated but was resolved for an unknown reason. The facility's policy on comprehensive care plans requires the development of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. However, the facility did not adhere to this policy, resulting in the lack of a care plan for the resident's respiratory needs.
Failure to Update Dialysis Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan related to dialysis services for a resident with end-stage renal disease. The resident was admitted with a diagnosis of end-stage renal disease and had active physician orders for dialysis three times a week. However, the care plan was not updated to reflect the correct dialysis schedule and transportation times. The care plan showed outdated times, while the actual dialysis schedule and transportation times had changed. This discrepancy was confirmed through interviews with the resident, staff members, and a review of the dialysis list on the whiteboard in the nurses' station. The Director of Nursing (DON) and other staff members confirmed that the care plan had not been updated to reflect the new dialysis schedule. The transportation staff admitted to forgetting to notify the Minimum Data Set (MDS) staff of the changes, which led to the care plan not being revised. The facility's policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not done in this case. The failure to update the care plan resulted in inconsistencies in the resident's dialysis schedule and transportation arrangements.
Failure to Provide Appropriate Wound Care and Documentation
Penalty
Summary
The facility failed to assess and provide appropriate wound care for two residents with non-pressure related skin conditions. Resident #15 was observed multiple times with undated and unchanged dressings on both ankles, despite having orders for wound care on the left leg only. The facility's records showed inconsistencies and gaps in documentation, with no wound care orders for the right leg and missed treatments for the left leg. The Regional Nurse Consultant and Director of Clinical Operations confirmed the discrepancies and lack of proper wound care documentation and assessment. Resident #71 was observed with an undated dressing on the inner left elbow, which had drainage. The dressing was applied after the resident bumped their arm, but there were no immediate wound care orders documented. The facility's records showed that the physician and the resident's spouse were notified a day after the incident, and the wound care order was only received three days later. The care plan for Resident #71 included skin inspection and monitoring, but the facility failed to document and address the wound promptly. The facility's policies on wound treatment management and change in condition were not followed, leading to inadequate wound care and documentation for both residents. The lack of timely assessment, proper documentation, and adherence to physician orders and facility protocols resulted in deficiencies in the care provided to Resident #15 and Resident #71.
Failure to Implement Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure a pharmacy recommendation and physician order was implemented for a resident during the monthly drug regimen review. The resident, who had diagnoses including major depressive disorder and other mood disorders, had a current order for Seroquel to be administered twice daily. The Consultant Pharmacist recommended adding an order to monitor for behaviors related to the use of Seroquel, which was agreed upon by the Director of Nursing (DON). However, no further action was taken to add the order. The DON confirmed that the recommendation was missed and not implemented.
Failure to Monitor Side Effects of Medications
Penalty
Summary
The facility failed to monitor side effects for a resident related to diuretic therapy and pain medication. Resident #63, who has multiple diagnoses including neuromuscular dysfunction of the bladder, pain in the right hip, obstructive and reflux uropathy, acute kidney failure, and chronic kidney disease stage 3B, was observed in bed and confirmed she had wounds and received all her medications. The Minimum Data Set indicated severe cognitive impairment and the resident was receiving diuretic medication. The active physician orders included various medications such as acetaminophen, furosemide, oxycodone, and tamsulosin, and treatments like wound care and pain evaluation. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that medications and treatments were administered as ordered, but there was no documentation of monitoring for side effects of the pain medication and diuretic therapy. The care plan for Resident #63 included interventions for pain management and monitoring for side effects of pain medication, such as observing for constipation, agitation, confusion, hallucinations, nausea, vomiting, dizziness, and falls. However, during an interview, a Licensed Practical Nurse/Unit Manager confirmed that there was no monitoring for side effects of the pain medication and diuretic therapy, acknowledging that such monitoring should have been in place. This lack of monitoring represents a deficiency in the resident's care, as the facility did not adhere to the care plan's requirements for side effect monitoring.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5.00%. During observations, record reviews, and interviews, it was found that twenty-five medication administration opportunities were observed, and four errors were identified for two residents. These errors resulted in a 16% medication error rate. Specifically, on 5/19/24, a Registered Nurse (RN) administered Divalproex Delayed Release 250 mg and Magnesium Oxide 400 mg to a resident at 2:09 p.m., which was past the scheduled time of 1:00 p.m. for both medications. The RN confirmed the late administration, which was also reflected in the Medication Administration Record (MAR) showing the medications were dispensed at 2:10 p.m. and 2:11 p.m. On 5/20/24, a Licensed Practical Nurse (LPN) administered multiple medications to another resident, including a Multi Vitamin with mineral and Famotidine 10 mg. The MAR review revealed that the Multi Vitamin with mineral was not in accordance with the physician's order, which did not include minerals, and the Famotidine was administered at 10 mg instead of the ordered 20 mg. The facility's policy on medication administration, which includes verifying the MAR and administering medications within 60 minutes of the scheduled time, was not followed in these instances.
Infection Control and Eye Drop Administration Deficiencies
Penalty
Summary
The facility failed to implement an effective infection control program related to adhering to transmission-based precautions for one resident and the proper administration of eye drops for another resident. Specifically, a registered nurse entered the room of a resident on contact precautions for C. diff without donning a gown or gloves, despite clear signage and instructions. The resident was receiving Vancomycin for C. diff, and the nurse acknowledged the oversight but justified it by stating she was only checking on the resident's call light. The infection preventionist confirmed that the nurse's actions were inappropriate and not in line with the facility's infection control policies. Additionally, a licensed practical nurse administered eye drops to another resident without wearing gloves. The nurse sanitized her hands before entering the resident's room but did not follow the proper procedure for administering eye drops, which includes wearing gloves and performing hand hygiene between administering drops to each eye. The facility's policy on the administration of eye drops clearly outlines the need for gloves and hand hygiene to prevent contamination and infection. The infection preventionist confirmed that the nurse should have worn gloves and followed the proper procedure as per the facility's policy.
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Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — 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.
Illustrative
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Illustrative
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Nursing homes near Sebring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palms At Sebring Nursing And Rehabilitation The | 0.5 mi | ★★★★★ | 2 | 0 |
| Oaks At Avon | 9.3 mi | ★★★★★ | 1 | 0 |
| Royal Care Of Avon Park | 11 mi | ★★★★★ | 1 | 0 |
| Lake Placid Health And Rehabilitation Center | 12.1 mi | ★★★★★ | 2 | 0 |
| Vivo Healthcare Wauchula | 23.1 mi | ★★★★★ | 0 | 0 |
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