Vivo Healthcare Laurellwood

Inspectors wroteBased on interviews and record review the facility neglected to adequately supervise residents to prevent sexual abuse for two residents (#2 and #3) out of two residents reviewed, resulting in resident-to-resident sexual abuse.

Inspectors wroteBased on interviews and record review, the facility failed to implement care plan interventions related to hypersexual behaviors for one resident (#2) of two residents reviewed.

Inspectors wroteBased on observations, record review and interviews, the facility did not ensure food service safety standards were followed in the kitchen and in one of one nourishment rooms.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#4) of two residents reviewed for PASARRs.

Inspectors wroteBased on record review, and interviews, the facility failed to implement care plan interventions related to falls/accidents for one resident (#14) of three residents sampled.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure residents received Activities of Daily living (ADL) care related to showers for one resident (#16) of three residents sampled. On 08/18/2025 at 09:48 A. M., an interview was conducted with Resident #16. The resident stated showers were not being provided by the facility staff. The resident stated showers were desired and requested from facility staff and the resident stated the facility staff refused to provide the showers. Review of a Certified Nursing Assistant (CNA) Kardex (a care documentation sheet showing individual resident's care needs), showed question 3 asked the type of bathing preferred. The response to type of bathing, revealed the resident was not provided preferred showers on 07/30, 08/06, 08/10, and 08/13 of 2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective pain management was provided consistent with professional standards of practice and the comprehensive person-centered care plan for one resident (#7) out of 14 residents on a pain management program.

Inspectors wroteBased on observations, interviews, and policy reviews the facility failed to ensure a clean and homelike environment on two units (Unit 1 and Unit 2) out of two units related to cleanliness of resident areas, cluttered halls and dining room, linen supply, and an unkempt courtyard for three days (9/11/23, 9/12/23 and 9/13/23) of three days of the survey.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to ensure residents were free from accident hazards related to: 1. hot water temperatures were not maintained at a safe temperature in two community shower sinks (located near room [ROOM NUMBER] and room [ROOM NUMBER]) and two resident bathroom sinks (room [ROOM NUMBER] and room [ROOM NUMBER]), 2. a storage room and supply room being unlocked with multiple housekeeping and nursing supplies, 3. emergency cords missing or unable to be used in three resident bathrooms (Rooms15/16, room [ROOM NUMBER] and room [ROOM NUMBER]), 4. a bathroom light not working in one resident shared bathroom (Rooms 15/16) and 5. an air conditioning unit in disrepair and leaking in one resident room (20) for a period of three days (9/11/23, 9/12/23 and 9/13/23) of a three day survey.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure storage and labeling of drugs and biologicals in accordance with professional standards, and failed to ensure medications were secured and not accessible to residents, visitors and/or unauthorized staff for one medication cart (Station Two) of two medication carts, and for one of one treatment carts located in an unlocked medical supply room for two days ([DATE] and [DATE]) out of three days of the survey.

Inspectors wroteBased on observation, record review and interview the facility failed to serve food that was palatable and at an appetizing temperature for six residents (#12, #16, #38, #40, #41 and #343) of 17 residents reviewed for food services.

Inspectors wrote2. An observation on 09/11/23 at 7:47 a.m., showed blue underwear hanging on a towel rack in the shared bathroom between Resident rooms [ROOM NUMBERS]. (Photographic Evidence Obtained) During an interview on 09/11/23 at 7:47 a.m., Resident #344 stated the underwear belonged to Resident #8. Resident #344 stated, Resident #8 washed them in the sink and was letting the underwear hang dry. During an interview on 09/11/23 at 8:50 a.m., Resident #8 stated the blue underwear was hers and she washed them out in the sink and left them to dry. Resident #8 stated she was being discharged tomorrow and wanted them clean for when she got discharged tomorrow. An observation on 09/11/23 at 9:17 a.m., showed a pair of used gloves on the corner of bed B in Resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide equal access to quality care related to a dignified meal service for two (#2 and #3) of four residents sampled for dependence on staff during dining.

Inspectors wroteBased on record review and interview the facility failed to request a Level II Pre-admission Screening and Resident Review (PASARR) for one resident (#16) with a newly diagnosed mental illness out of 14 sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed to monitor and record temperatures for the one nourishment refrigerator used for residents located at one nurses station (Nurses Station Two) of two nurses stations.

Inspectors wroteBased on record review and interview, the facility failed to ensure the binding arbitration agreement was understood by two residents (#13 and #34) of three residents sampled.

Inspectors wroteBased on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a recertification survey that was conducted 9/11/23 to 9/13/23 and was cited F761 and F880. On 11/2/23 a revisit survey was conducted, and the facility was recited F761 and F880. The facility had developed a Plan of Correction with a completion date of 10/13/23.

Inspectors wroteBased on observations, record review, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety regarding not dating pre-made sandwiches on one of one tray observed in the walk-in refrigerator, not documenting food temperatures prior to serving for one out of eleven meals on the temperature log, and not ensuring food from an outside source was stored with a use-by date and labeled with the owners name in one of one nursing station refrigerator.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that a care plan was developed related to behaviors for one resident (Resident #41) out of the sampled twenty-five residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and four errors were identified for three (3) (Resident #10, #23 and #46) of six (6) residents observed. These errors constituted a medication error rate of 16 percent.