Vivo Healthcare Gateway

Inspectors wroteBased on record review and policy review, the facility failed to perform a thorough investigation following an allegation for one resident out of three, (#1). Findings Included: During an interview on 01/07/2026 at 10:18 AM, Resident #1 stated an incident happened two weeks prior while she was being changed by a CNA (Certified Nursing Assistant). Resident #1 stated she was on her bed being pressured by an aide, while being changed. The resident stated the right and left forearms were crossed, both palms facing down and stated having asked the CNA, What are you doing. The resident stated she was on the right side of the bed. The wheelchair was facing a nightstand on the right of the bed. She stated the arms were crossed one over the other and pressed against the surface of the bed and wheelchair. Resident #1 stated having hurt wrists and bruising on her forearms. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner, and food was prepared and stored in accordance with professional standards for food safety in one out of one facility kitchen and two out of two nourishment rooms.

Inspectors wroteBased on observations, staff interviews, and facility record review, the facility failed to ensure a working and properly maintained dish washing machine in the kitchen, during two of four days observed, (3/18/2024, and 3/19/2024). It was determined the low temperature chemical sanitizer dish washing machine either; 1. Was not meeting required wash and rinse temperatures, and 2. The chemical sanitizer was allocated and delivered well over acceptable ranges.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#7, #13, #14, #20, #50, #53, #65, #80, #88 and #170) of fifteen residents sampled for PASRR review.

Inspectors wroteBased on observations, interviews, and record review the facility failed to have activities available and provide adequate space for activities for 52 residents residing on one of one memory care units.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and five errors were identified for five ( #57, #83, #7, #76, and #98) of eleven residents observed. These errors constituted a 18.52% medication error rate.

Inspectors wroteBased on observation, interviews and review of the facility's policy titled Pest Control Program, the facility failed to maintain an effective pest control program, for two of two units and the kitchen, as evidenced by observation of pests on four (03/18/2024, 03/19/2024, 03/20/2024 and 03/21/2024) of four survey days.

Inspectors wrote2. Review of Resident #169's medical record revealed he was admitted to the facility on [DATE] with diagnosis that included Fusion of spine, and Torticollis. Review of the residents Brief Interview For Mental Status (BIMS), dated 3/1/24, revealed a score of 13 (Cognitively intact). Observation on 03/18/24 at 11:17 AM of Resident #169's name posting located on the wall outside of his room door revealed a name normally referred to a female. Observation of the resident at this time revealed the resident had facial hair consisting of a beard and goatee. Interview with Resident #169 at this time revealed that they identify as he/him/they and prefers to be referred to as an alternate name he had provided to staff. The resident reported he prefers to have his provided name posted outside of his room. [...]

Inspectors wroteBased on interviews and record review, the facility failed to refer three residents (Residents #5, #54 and #70) of fifteen residents reviewed for Level I Pre-admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II PASARR resident review upon a significant change in status assessment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 (#98, #100) residents reviewed for vision and dental services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consistently provide a packaged meal for one resident (#87) out of four residents receiving dialysis.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure one (South #2) of four medication carts was locked while unattended, medications were secured, medications were stored per manufacturer guidelines, one (South) of two treatment carts were locked while unattended, and medications were not stored with cleaning materials.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an appropriate infection control program related to ensuring staff were aware precaution measures for one (#80) of one residents with precautions, provide a cleanable mattress for one (#95) out of 52 residents, and to ensure adequate hand hygiene was performed for staff and residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the handrail in one (South - Memory Care) of two units was secure and did not cause a safety issue regarding the presence of broken and/or missing components.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for one resident unit (Secured Unit) out of two resident units in the facility.

Inspectors wroteBased on observations, interviews and policy review the facility did not ensure dignity was maintained for residents on one unit (South Unit) of two units for four days (12/13/21, 12/14/21, 12/15/21, and 12/16/21) of 4 days related to failure to provide furnishings in resident rooms to include lack of pillows, blankets, and personal effects and 2. failed to ensure fitted clothing for one resident (#306) of a total of sample of 41 residents.

Inspectors wroteBased on observations, interviews, record review and policy review the facility failed to ensure resident smoking materials were secured for three of four days (12/13/21, 12/14/21 and 12/15/21) on one unit (North Unit) of two units for seven residents (#39, #91, #18, #76, #74, #37, and #15) for a total sample of seven residents who smoked on the North Unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report an alleged allegation of neglect related to an elopement to regulatory agencies as mandated for one resident (#49) out of 41 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a care plan problem area with a goal and interventions was developed related to Isolation Precautions, for one resident (#156) of forty-one sampled residents

Inspectors wroteBased on resident interview, family interview, staff interview and record review the facility failed to provide a timely discharge for one resident (#45) out of 41 sampled residents. Resident #45 had an increase in anxiety related to her discharge which resulted in an increase in her antianxiety medications. The facility was made aware on 9/9/21 that all Comprehensive Assessment and Review for Long-Term Care Services (CARES) applications must be submitted via email. The application was not resubmitted until 9/28/21.

Inspectors wroteBased on observations, staff interview and record review the facility failed to ensure one of one walk in freezers was operating in a manner to be free from ice blocking and heavy frosting. It was observed that heavy ice was formed on the ceiling, motor fan housings, shelving, and various packaged food items for two days of four days observed (12/13/2021 and 12/16/2021).

Inspectors wroteBased on observations, interviews, and review of facility records, the facility failed to ensure resident rooms and other spaces in two of two units (North and South), were clean and free from disrepair during four of four days observed (10/4/20, 10/5/20, 10/6/20 and 10/7/20).

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure one (#88) of 39 sampled residents had a care plan implemented related to supervision for frequent falls.

Inspectors wroteBased on observations, medical record review, and staff interviews, the facility failed to ensure one (#94) of one resident sampled for tube feeding out of 6 residents in the facility received tube feed nourishment in accordance with the physician order for two of four days observed (10/4/20 and 10/5/20). It was determined that nursing staff did not start the feeding timely, and did not provided a physician's ordered flow rate of the product.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure medications were labeled properly and expired medications were disposed of, for two (Cart 2 South, Cart 3 North) of three medication carts observed during the medication storage task.

Inspectors wroteBased on observations, facility file review, and staff interviews, the facility failed to post the required Nurse Staffing Information to show the census, number of licensed and unlicensed staff working for each shift and the actual hours worked was posted for review daily.