Vivo Healthcare University

Inspectors wroteBased on interviews and record reviews, the facility failed to protect Resident #1's right to be free from neglect by Certified Nursing Assistant (CNA) A, by failing to implement sufficient safeguards and supervision to prevent Resident #1, one of four residents reviewed for Activities of Daily Living (ADL) care, from an avoidable fall with a subsequent left hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with bed mobility for Resident #1. On June 18, 2026, Resident #1's ADL care, including repositioning in bed/bed mobility, was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident subsequently fell out of bed during repositioning (rolling the resident to her side) and sustained a left hip fracture. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement sufficient safeguards and supervision to prevent one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with a subsequent left hip fracture. The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance with bed mobility for Resident #1. On June 18, 2026, Resident #1's ADL care, including bed mobility, was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the resident's care plan. The resident fell out of bed during repositioning (rolling the resident to her side) and sustained a left hip fracture. Any resident requiring two-person staff assistance was at risk. There were 19 residents who required two-person assistance with bed mobility at the time of the survey. [...]

Inspectors wroteBased on 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 residents who consumed foods from the facility's kitchen. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene for two (Residents #48 and #19) of three residents reviewed for ADL care from a total survey sample of 46 residents.

Inspectors wroteBased on observations, record reviews, interviews, and a review of facility policy, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #72) of one resident reviewed for accident hazards out of 46 residents in the total survey sample. Medicated ointments in plastic medication cups were left at the resident's bedside. Resident #72 had not been assessed for capability of self-administering/applying medicated ointments. No self-administration assessment was found in the record or provided by the facility during the survey. No care plan was located in the record indicating that the resident was capable of safely self-administering medications/medicated ointments.

Inspectors wroteBased on observations, interviews, record review, and 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 #34) of one resident reviewed for respiratory care, from a total survey sample of 46 residents. Resident #34 was not receiving oxygen at the flow rate ordered by her physician.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, by failing to provide dermatology consults as ordered for one (Resident #4) of four sampled residents.

Inspectors wroteBased on observations, interview, record review, and facility policy and procedure review, the facility failed to ensure the privacy and confidentiality of protected health information (PHI) for 15 of 15 residents receiving skilled therapy services, by posting a list of residents on the counter top of the East and [NAME] wing nurses' station, visible to other residents and guests.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain and implement an infection prevention control program to provide a safe, sanitary and comfortable environment. The facility staff failed to ensure the proper use of protective equipment (PPE) in transmission base precaution (TBP)/COVID-19 isolation room for three (Residents #3, #7, and #6) of four sampled residents; and the facility failed to ensure all staff used proper hand hygiene in a TBP room/COVID-19 isolation room (rooms [ROOM NUMBERS]). Failure to adhere to infection control and prevention protocol increase the risk of transmitting communicable diseases and infection.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #47) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, specifically, failure to apply physician-ordered, medicated cream/ointment to an ongoing rash.

Inspectors wroteBased on observations, medical record review, staff interviews, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. There were four errors and 33 opportunities for error, resulting in an error rate of 12.12% and involving two errors for Resident #50, one error for Resident #69, and one error for Resident #28.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that two of 33 sampled residents, Residents #187 and #73, who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Inspectors wroteBased on observations, resident and staff interviews, and medical record review, it was determined that the facility failed to ensure one of 33 sampled residents (Resident #59) received treatment and care in accordance with professional standards of practice for her skin rash and itching.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTI) for one resident (Resident #63) out of 3 residents with a Foley catheter in a total sample of 33 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Pharmacist recommendations of gradual dose reductions were reviewed and acted upon by the resident's physician in a timely manner for one of five residents (Resident #54) reviewed for unnecessary medications from a sample of 33 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Gradual Dose Reduction (GDR) recommendation was enacted in a timely manner for one of five residents reviewed for unnecessary medications (Resident #54) from a sample of 33 residents.

Inspectors wroteBased on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure Schedule II-V medications were stored in a separately locked compartment, permitting only authorized personnel to have access.