Vivo Healthcare West Orange

Inspectors wroteBased on interview, and record review, the facility failed to honor a resident's wishes for Do Not Resuscitate (DNR) by not ensuring those wishes were completely and accurately documented to promote continuity of care between providers for 1 of 10 residents reviewed for advance directives, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) efforts in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 would have experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 5:45 AM, resident #1 was found unresponsive with no pulse and no respirations. Registered Nurse (RN) C verified resident #1's code status as DNR, then called Emergency Medical Services (EMS). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident did not receive Cardiopulmonary Resuscitation (CPR) against his wishes by providing an invalid Florida Do Not Resuscitate Order (DNRO) form to Emergency Medical Services (EMS) during an emergency for 1 of 10 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:45 AM, resident #1 was found unresponsive with no pulse and no respirations. Registered Nurse (RN) C verified resident #1's code status as Do Not Resuscitate (DNR) and called EMS. RN C provided EMS with an incomplete Florida DNRO form. EMS determined the form was invalid due to missing signatures and began CPR. After three rounds of CPR efforts, EMS discontinued CPR at 6:40 AM and resident #1 was pronounced deceased . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate related to special treatments, procedures and programs for 3 of 3 residents reviewed for accuracy of assessments, of a total sample of 40 residents, (#4, #8 and #46).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment by failing to replace a cracked bedside floor mat for 1 of 1 residents reviewed for environmental concerns, of a total of 40 sampled residents, (#70).

Inspectors wroteBased on interview and record review, the facility failed to re-admit residents who were transferred to a higher level of care for treatment of acute conditions, for 2 of 3 residents reviewed for hospitalization, out of a total sample of 9 residents, (#2 and #3). The facility's failure to permit residents who required its care and services to return from the hospital resulted in extended stays in acute care settings after medical issues were resolved, and necessitated adjustment to unfamiliar personnel and routines in new skilled nursing facilities (SNFs), actual harm, for residents #2 and #3.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective communication, collaboration, and oversight of changes to the plan of care by members of the interdisciplinary team (IDT) for 1 of 3 residents reviewed for hospitalization, out of a total sample of 9 residents, (#2). The facility's failure to thoroughly review medication orders resulted in administration of an excessive dose of insulin that rendered a resident unresponsive due to a critically low blood glucose level, and required transfer to a higher level of care for treatment, actual harm, for resident #2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the right to a clean, comfortable, and homelike environment for 4 of 6 residents reviewed for environmental concerns out of a total sample of 9 residents, (#5, #6, #7, and #9), on 2 of 2 units, (A & B Wings).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely and effective pain management, according to professional standards of practice, for 1 of 1 resident reviewed for pain management out of a total sample of 9 residents, (#6).

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record accurately reflected the status of and services provided for 1 of 3 residents reviewed for hospitalization, out of a total sample of 9 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to medication error rates over 5%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders and standards of practice for residents who received their nutrition and medications through a gastrostomy tube (GT) for 1 of 2 sampled residents with a gastric tube (GT) out of a total sample of 29 residents, (#298).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 1 of 3 residents sampled for medication administration, (#298). There were 6 medication errors in 29 opportunities for a medication error rate of 20.69%.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications and biologicals under proper temperature controls as indicated by manufacturer's recommendations in 1 of 2 medications rooms, (A wing).

Inspectors wroteBased on record review and interview, the facility failed to comprehensively asses a significant change for 1 of 1 resident sampled for decline in Activities of Daily Living (ADL) of a total sample of 41 residents, (#33). Finding. Review of resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent for Bed Mobility, Transfers and Eating. The assessment showed the resident required supervision for Walking, Locomotion and Dressing. The facility assessed the resident as needing Limited Assistance of 1 staff for Toileting and Personal Hygiene. The resident was frequently incontinent of urine and bowels. Review of the quarterly MDS assessment dated [DATE] revealed the resident now required extensive assistance of 1 staff for Bed Mobility, Transfers, Toilet use and Personal Hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for assessment accuracy of a total sample of 41 residents, (#67).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dressing changes for a Midline Catheter according to professional standards of practice for 1 of 2 residents with Intravenous (IV) catheters of a total sample of 41 residents, (#335).

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and sanitary environment to protect the health and safety of residents, staff and the public by not securing bio-medical refuse and debris in the waste containers.