Vivo Healthcare West Orange

In the surveyor’s words

From the most serious findings on record at Vivo Healthcare West Orange, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Mar 5, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF678Mar 5, 2026

  Based 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 . […]

• Actual harm, isolatedF626May 10, 2024

  Based 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. Findings: 1. Review of the medical record revealed resident #3 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF684May 10, 2024

  Based 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. Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and last readmitted on [DATE]. […]

• No harm, potential for more than minimal, patternF584May 10, 2024

  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. […]