Vivo Healthcare West Orange

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including epilepsy, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the MDS quarterly assessment with assessment reference date (ARD) 2/21/25 revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated she was cognitively intact. The assessment indicated resident #4 received tracheostomy (a hole in the throat for breathing) care and dialysis. On 5/06/25 at 11:53 AM, resident #4 was reclined in bed with the head of the bed elevated. Resident #4 stated she did not go to dialysis. Resident #4 clarified she did not receive dialysis and had never received dialysis. 2. Resident #8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #70 was admitted to the facility on [DATE], with a history of falling, abnormal posture, unspecified lack of coordination. Review of resident #70's care plan with revision date of 7/11/23, indicated he was at risk for falls related to deconditioning, weakness, and having a history of a fracture. Interventions included fall mats at bedside, dated 12/30/24. On 5/05/25 at 3:23 PM, resident #70 was lying in bed, a beside fall mat was on the floor. The surface was cracked and split along its entire length which revealed the layer underneath the surface. On 5/06/25 at 8:40 AM, the beside fall mat was observed on the floor at the side of resident #70's bed. The surface remained cracked and split along its entire length which revealed the layer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: 1. Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, and a skin infection with surgical amputation of her right great toe. Review of a progress note dated 5/07/24 at 9:49 PM revealed resident #6 arrived on the A Wing and was assisted to her room. On 5/08/24 at 11:10 AM, resident #6's granddaughter expressed dissatisfaction with the condition of her grandmother's room and bathroom when she arrived from the hospital the previous night. She stated it was obvious the room had not been properly cleaned and prepared for a new resident. The granddaughter provided photographs that showed stained sheets on the bed, a significant amount of dried,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, a skin infection with surgical amputation of her right great toe, peripheral vascular disease, and heart disease. Resident #6 had a care plan for risk for pain related to her right foot wound initiated on 5/08/24. The goal was the resident would not have interruptions in normal activities due to pain. The care plan interventions included administer pain management as ordered, and monitor and record pain characteristics such as quality, severity, anatomical location, onset, and duration. The document instructed nursing staff to monitor, record, and report the resident's complaints of pain or requests for pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and last re-admitted on [DATE]. His diagnoses included type 2 diabetes with long-term insulin use. Resident #2 had a care plan for diabetes with use of insulin, initiated on 12/14/23. The goal was the resident would have no complications related to diabetes. The interventions instructed nurses to check his blood glucose levels and administer diabetes medication as ordered by the physician. A nursing progress note dated 2/16/24 revealed at approximately 3:50 AM, resident #2 was discovered unresponsive in bed with a critically low blood glucose level. The resident's physician gave an order to send the resident to the hospital via 911 for further evaluation. Review of a Hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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%. Findings: Review of the facility's survey history revealed repeat deficiencies concerns for medication errors over the past 5 years, and again during the current survey related to a medication error rate of 20.69%. The survey history revealed facility error rates of 6.45% on 2/10/22, 10.71% on 1/16/20 and 6.25% on 10/25/18. This will be the facility's fourth deficiency in 5 years for mediation error rate equal to or greater than 5%. On 7/13/23 at 5:18 PM, 6:23 PM, and 6:26 PM interviews were conducted with the facility's Administrator, Interim Director of Nurses (DON), and Corporate [NAME] Present (VP) of Operations regarding the facility's QAPI program. The Administrator verified they completed a plan of correction for medication errors last year but could no locate current audits for this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Review of resident #298's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included diabetes mellitus type 2, dysphagia (difficulty swallowing), and gastrostomy tube. A gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach (www.medlineplus.gov retrieved 08/01/23). Resident #298's Nursing Comprehensive assessment dated [DATE], revealed he was oriented to self, non-verbal, totally dependent on staff for his activities of daily living and received nutrition via tube feeding. The physician order dated 7/9/23 instructed nurse to flush tube with 30 ml (milliliters)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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%. Findings: Review of resident #298's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included diabetes mellitus type 2 (DM), dysphagia (difficulty swallowing), hypertension, anemia, benign prostatic hyperplasia (BPH), and gastrostomy tube. A gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach (www.medlineplus.gov retrieved 08/01/23). On 7/11/23 at 9:40 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #289's scheduled morning medications. LPN A placed 8 different medications into 8 small plastic cups at the medications cart that included, Vitamin C 500 milligrams (mg) 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). Findings: On 8/24/21 at 4:12 PM, the A wing medication room refrigerator was opened by Registered Nurse (RN) B and the thermometer inside was immediately read at 48 degrees Fahrenheit (F). The door of the refrigerator was closed at the request of State Survey Agency staff and on 8/24/21 at 4:14 PM, the Assistant Director of Nursing (ADON) opened the door and validated the temperature on the thermometer inside the refrigerator still read 48 degrees F. The ADON explained the 11:00 PM to 7:00 AM shift nurse was supposed to check the refrigerator's temperature every night. On 8/24/21 at 4:19 PM, the Director of Nursing (DON) stated if the refrigerator temperature was out of range, the nurse was expected to initiate a maintenance request. She explained the refrigerator was frozen earlier that day and the temperature was raised to defrost it. The ADON again opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The assessment showed the resident had declined and was now always incontinent of urine. On 8/26/21 at 4:56 PM, the resident's status was discussed with the Assistant Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #67 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbances and morbid obesity. Resident #67's MDS annual assessment with assessment reference date of 7/19/21 revealed he received insulin injections on 7 of 7 days in the look-back period. Review of resident #67's medical record revealed no physician orders for insulin. Review of the Medication Administration Record (MAR) did not reflect injections administered. On 8/26/21 at 12:30 PM, the Director of Nursing (DON) stated the staff who completed the MDS assessment worked part-time and was not currently present in the facility. During review of the MDS assessment with the DON, she acknowledged the assessment was inaccurate. She stated she reached out to Registered Nurse A, the MDS coordinator, who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). Finding: Resident #335 was admitted to the facility from a specialty hospital on 8/21/21 with diagnoses of respiratory failure, chronic obstructive pulmonary disease, and lung cancer. On 8/23/21 at 11:10 AM, resident #335 was observed in bed with a Midline IV Catheter to her left upper arm. The transparent dressing that covered the IV site was dated 8/14/21, and the lower end of the dressing was lifted from her skin. Resident #335 stated the IV was inserted at the hospital, and she was unsure if she was getting medications through it. A Midline Catheter is a small tube used to give treatments and to take blood samples. It is inserted into a vein in your arm . the end of the tube does not go past the top of the armpit . it can stay in place up to 30 days(retrieved on 8/27/21 from www.drugs.com). On 8/24/21 at 9:55 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Finding: On Monday, 8/23/21 at 10:00 AM, the entrance/exit door of the facility's Corona Virus Disease 2019 (COVID 19) unit had large, red, bio-medical waste containers overflowing with bio-medical refuse. The containers were filled past capacity with bio-medical waste and the container lids could not be closed. On top of the container lids were several bags of bio-medical waste. Some of these bags were partially open with debris coming out of the bags. The Director of Nursing (DON) arrived in the area and stated she was not aware the waste bins were full. At 10:51 AM, the DON and the B Wing Unit Manger opened a storage shed that contained approximately 12 smaller empty bio-medical waste bins. At the opposite end of the rear parking area, near the maintenance building were 21 large, red, bio-medical waste bins which were full. On 8/23/21 at 11:24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.