Vivo Healthcare Orange Park

Inspectors wroteBased on observations, interviews, facility document review, and the facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #95) of four residents reviewed for respiratory care, in a total survey sample of 28 residents. Resident #95 did not receive oxygen at the flow rate ordered by his physician.

Inspectors wroteBased on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all the residents who consumed foods in the facility. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to maintain the kitchen freezer in a safe operating condition with the potential to place the health of all the residents who consumed foods in the facility at risk. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for maintaining essential equipment in the kitchen. Specific instruction on kitchen equipment is important in health care settings serving nursing home residents. Freezer units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy and procedure review, the facility failed to implement a culturally competent, person-centered care plan for the use of assistive devices and a translation/interpreter service for communication, and the correct contact information for the contracted translator services for one (Resident #41) of three residents whose primary language was not English, from a total sample of 33 residents. The staff did not have a way to communicate with Resident #41 except to have her point at things. They relied on her family and staff who spoke her language (if they were available or on duty). The staff was unable to consistently communicate effectively with Resident #41 in a language she understood. Failure to develop and implement the care plan can result in negative health outcomes for the residents.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy and procedure review, the facility failed to provide necessary care and services to ensure a resident's ability to communicate, by failing to provide assistive devices for communication and correct contact information for the contracted translator services for one (Resident #41) of three residents whose primary language was not English, from a total sample of 33 residents. The staff did not have a way to communicate with Resident #41 except to have her point at things. They relied on her family and staff who spoke her language if they were available or on duty. The staff was unable to consistently communicate effectively with Resident #41 in a language she understood. Inability to make her needs known due to a language barrier may result in isolation, depression and unmet needs.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that two (Residents #85 and #69) of a sample of 33 residents who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain grooming and personal hygiene for fingernail care and trimming.

Inspectors wroteBased on resident, family, and staff interviews, and medical record review, the facility failed to ensure that one (Resident #85) of a sample of 33 residents, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #50) of 16 residents receiving respiratory treatments, from a total sample of 33 residents, received the correct number of liters of oxygen as ordered by the physician.

Inspectors wroteBased on observation and interview, the facility failed to perform hand hygiene during medication administration for one (Resident #37) of three residents observed during medication administration. This practice has the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on observations, resident/staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure that a resident with a pressure ulcer, received necessary care and services, consistent with professional standards of practice, to promote healing and prevent worsening of the pressure ulcer for one (Resident #75) of four residents reviewed for pressure ulcer development, from a total of 35 residents in the sample. The facility failed to reposition the resident to reduce the pressure on her coccyx/sacral area, and failed to provide the resident with a pressure-reducing mattress when the wound was discovered on 05/12/2021. This contributed to worsening of the pressure area from a Stage II to an unstageable wound.

Inspectors wroteBased on record reviews and interview, the facility failed to monitor targeted behaviors for residents who were receiving psychotropic medications, and/or failed to monitor for drug-related side effects for four (Residents #25, #72, #330 and #381) of five residents reviewed for the use of psychotropic medications, from a total of 35 residents in the sample.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews and facility policy and procedure review, the facility failed to provide reasonable accommodation of individual needs by ensuring one (Resident #11) of 35 sampled residents from a total of 84 residents had access to his call light at all times.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide services which met professional standards of quality for during medication administration. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice.

Inspectors wroteBased on observations, clinical record review and resident/staff interviews, the facility failed to ensure one (Resident #75) of one resident sampled for mobility, from a total of 35 sampled residents, received appropriate treatment and services to prevent further worsening of a left hand contracture.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (Resident #20) of one resident reviewed for accidents, from a total of 35 residents in the sample.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide routine drugs for two (Resident #17 and Resident #75) of seven residents reviewed for compliance with medication administration, from a total of 35 residents in the sample.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medication error rates were not five percent or greater. There were 44 opportunities for error with a total of three errors, resulting in a medication error rate of 6.81% and involving two (Residents #75 and #17) of seven residents observed during medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #17) of seven residents reviewed for medication administration, from a total of 35 residents in the sample.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for three (Residents #75, #76 and #67) of seven residents observed during medication administration. The facility staff pre-poured medications and stored them in a medication cart with only the residents' first names written on the medication cups.