Vivo Healthcare Gandy

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident rights were honored, related to advance directives and code status, for one resident (#1) out of three residents sampled. On [DATE], facility staff initiated cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury), on Resident #1 when the resident was found unresponsive for approximately twelve minutes. Failure to honor the resident's wishes for Do Not Resuscitate (DNR) caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. [...]

Inspectors wroteBased on interviews with the facility's nursing and administrative staff, record review and review of the facility policies, the facility administration failed to utilize their resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for five residents (#3, #4, #5, #6 and #8) out of five residents sampled for abuse and neglect, putting all the residents of the facility at risk for ongoing abuse and neglect. [Cross reference F609 and F610].

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure infection control practices were consistently followed to notify visitors of an influenza outbreak and/or offer personal protective equipment (PPE) such as masks prior to entering the resident care area and in nebulizer masks were not stored in a manner to prevent infection in two of four units (100 and 300). Findings Include: On 1/28/26 at 9:10 a.m. during the initial tour of the facility, all staff members observed in the resident care area were wearing masks. When asked, staff stated that mask use was required due to an influenza (flu) outbreak. Upon further review of the lobby area, no signage was posted to notify visitors of the outbreak or to recommend appropriate personal protective equipment (PPE) and the receptionist did provide information or instructions about the influenza outbreak. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide staff with adequate training on issues regarding language barriers reported through grievances via the resident council and residents in seven of seven grievances sampled for review.

Inspectors wroteBased on record review, interviews and review of the facility policy, the facility failed to ensure allegations of abuse and neglect were reported in a timely manner for four (#3, #4, #5 and #6) of five residents reviewed.

Inspectors wroteBased on record review, interviews and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse and neglect in a timely manner for four residents (#3, #4, #5 and #8) of five residents reviewed.

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure one of two community shower rooms were maintained in a clean and sanitary condition.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure resident's with diagnosed mental illness or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) screenings for four residents (#47, #79, #19, and #73) out of 29 residents sampled.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement care plan interventions for four residents (#19, #24, #32, and #133) of thirty-nine sampled residents, related to; 1. Fluid restrictions, 2. Self-administration of oxygen, 3. Discharge planning, and 4. Fall interventions.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one resident (#118) of two residents sampled for non-pressure related skin conditions received wound care as prescribed by the physician.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the intravenous (IV) access of one resident (#5) of three residents with IV access was maintained in accordance with professional standards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure effective communication with the Dialysis center that provides treatment services for one resident (#119) of three sampled residents. It was determined review of fourteen Dialysis service visits, the Dialysis nursing staff failed to collaborate with the nursing facility by not providing and documenting post weights, vital signs, Dialysis vascular access site status, and what Dialysis treatment was provided.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions and don Personal Protective Equipment in accordance with facility policy for one resident (#118) of thirty-nine sampled residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure three (#88, #124, #102) of 54 residents sampled were provided services to maintain grooming, and personal and oral hygiene.

Inspectors wroteBased on record review, policy review, observations, and interviews the facility did not ensure appropriate treatment and services were in place for a central line and did not ensure that practice standards were followed related to the a central intravenous catheter for one resident (#83) of three residents with central lines.

Inspectors wroteBased on observation interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in regards to not following appropriate infection control related use of PPE (personal protective equipment) for rooms under contact and droplet precautions, failure to ensure that a cleaning and disinfecting process was utilized after use of a multiuse glucometer device for 4 (#27, #9, #12, #77) residents, and failure to practice hand hygiene prior to donning and after doffing gloves.

Inspectors wroteBased on observation, interview and record review the facility failed to honor residents' right to smoke for 2 of 14 (#11, #86) residents who smoke.

Inspectors wroteBased on interview and record review the facility failed to appropriately investigate the concerns of the resident council group and keep them apprised of the resolution of the concern bought up by the resident council group.

Inspectors wroteBased on observation, interview, medical record review, and manufacture's directions the facility failed to ensure three (400 unit cart #1, 100 unit cart #1, and 300 unit cart #2) of four sampled medications carts had medication and biologicals stored not past the expiration date, and/or failed to document an open on date. Findings Included: 1. On 5/17/2021 at 1:00 p.m. medication cart #1 on the 400 unit was observed with the following: An oral inhaler Combivent. The inhaler did not contain an open on date. The instructions on the inhaler read to discard three months after opening. A second oral inhaler labeled Breo-ellipta did not contain an open on date. The label indicated to discard 6 weeks after opening. A bottle was labeled assure platinum strips. The bottle did not contain an open on date. vial labeled NovoLog contained an open on date 4/8/2021. [...]