Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
The findings include:
On 5/16/2021 at 3:10 pm, Resident #59 was observed in her room, rubbing under her chin and her arms.
She voiced a complaint of constant itching. She stated staff tell her it is anxiety, but she doesn't think it is
anxiety. A tube of Cortisone 10 cream which was observed to be almost empty was seen next to her bed.
She lifted her shirt several times and it appeared red under her shirt area. She stated it itched on her arms,
neck, and chest.
On 05/18/21 at 8:30 AM, Resident #59 was observed sitting up in bed. She was lightly scratching her
bilateral upper arms, not causing any scratches to appear. No rash was observed on her arms. She was
asked if her skin was itchy. She replied, Yes, my arms, my chest, my back and my abdomen. Not my legs.
She was asked if staff was aware and she stated, Yes, they know. They've looked at it and prescribed some
medicine and cream for it.
On 05/18/21 at 10:15 AM, Employee F she was asked if she had seen Resident #59's rash. She stated,
Yes, I was asked to see her last week for that. It's not really a wound, so I wasn't planning on seeing her
again, but if it's still going on, she may need a derm (dermatology) consult. I know we did prescribe an
ointment. I'll check in and see how's she is doing.
On 05/18/21 at 1:30 PM, Employee A was confirmed that she was caring for Resident #59 today. She
stated that she know the resident well and was aware of her itchy rash. She replied Yes, she's getting a
cream for that 3 times a day.
A review of progress notes for Resident #59 shows an entry on 5/5/2021 by her primary physician's nurse
practitioner at 9:15 am which stated: Patient is a [AGE] year old Caucasian female that presents today with
mildly worsening itching and puritis to her arms and chest in March with an underlying diagnosis of acute
rash. The patient was started on Prednisone for a few days and Calamine lotion for the itching and she has
not used it for over a month.
The next note in relation to Resident #59's rash was on 5/11/2021 as a wound progress note. The note
stated, Chief complaint- Initial wound care, consult requested by (primary physician). Patient presents today
with c/o (complaints of) pruritic to the upper extremities and chest. Diagnosis 1: Rash. Diagnosis 1 planstart Triamcinolone 0.1% cream to bilateral upper extremities, axilla and chest
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
105366
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
BID (twice a day) for itching.
Level of Harm - Minimal harm
or potential for actual harm
A review of the resident's hard copy medical record revealed an order written on 5/11/2021 which stated,
Triamcinolone 0.1% cream to chest and bilat upper extremities/axilla for itching.
Residents Affected - Few
A review of the resident's electronic medical record showed an order entered on 5/11/2021 at 14:30 which
stated: Triamcinolone 0.1% cream Apply to BUE/axilla and chest topically as needed for itching. Give TID
(three times a day) PRN (as needed).
A review of the resident's electronic Treatment Administration Record shows this order added on 5/11/2021.
The record did not show the cream was administered on any date in May 2021.
On 05/19/21 at 1:50 PM, the treatment cart was observed with Employee E, RN. There was one tube of
Triamcinolone Acetonide Cream which was in a baggie and had a pharmacy label with Resident #59's
name and instructions which matched the current order. Inspection of the tube showed it had been opened,
but it appeared to almost full with a minimum amount of cream missing from the tube. The nurse was asked
if she had ever applied this cream to Resident #59. She stated, No, I don't think I have.
On 05/19/21 at 2:00 PM Resident #59 was observed lying in her bed with her head elevated. She was
scratching both arms. When asked how her rash was feeling today she stated, It's terrible. Nobody is putting
any cream on it; I have to do it myself. An empty tube of cortisone 10 1% cream was observed on her
bedside table. She confirmed she had been applying it to herself and stated, Yes, and my brother brought
me two more tubes. A small, brown paper bag was observed on her table which she then opened to show
two more tubes of Cortisone 10 1% cream. Employee G was in the room at that time and asked if Resident
#59 has ever told her that she is itchy. She stated, Yes, I tell the nurse and she puts cream on her.
Employee E then entered the room was asked if she knew Resident #59 had her own Cortisone 10 1%
cream that she was applying herself. She stated, That's new, we're not sure where that came from.
A review of Resident #59's current orders on 05/20/21 at 8:36 AM did not include a consult ordered for
dermatology. Current orders did not show an order for Cortisone 10 1% cream, nor an order for
self-administration of this or any medication.
The facility policy and procedure for self administration of medication (11/2017) was reviewed. The purpose
of the policy stated, To provide guidance for patients wishing to self-administer medications.
Review of the medical record/chart for Resident #59 did not reveal that she was evaluated for
self-administration of medications.
A review of the facility policy and procedure for Medication and Treatment Administration Guidelines
(7/2006, updated 3/2018) stated: PRN medications require an outcome evaluation after administration.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 2 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
During the initial tour on 05/16/21 at 02:33 PM, Resident #63 was observed lying on the bed. The Foley
catheter tubing had cloudy drainage. Another observation on 5/17/21 at 9:00 AM, revealed the resident
lying on the bed facing the door. The catheter bag was in a privacy bag, but cloudy drainage was flowing
through the tubing.
Record review indicated that Resident #63 was admitted to the facility on [DATE]. Diagnoses included
pneumonia, disease of stomach and duodenum, encounter for surgical aftercare following surgery on the
digestive system, obstructive reflux uropathy, methicillin resistant staphylococcus aureus (MRSA), history of
malignant neoplasm of prostate, and retention of urine. Resident #63 had physician orders for Foley 16fr
/10ml for prostate cancer and urinary retention, complete blood count and complete metabolic panel for
hematuria, lidocaine (anorectal cream 5%) apply to the tip of the penis every shift for pain and change
Foley catheter every 30 days. Review of the care plan revealed that the resident had a UTI with intervention
to monitor/report to physician for signs and symptoms of UTI such as: urgency, malaise. foul smelling urine,
dysuria (pain on urination), hematuria(blood in urine), fever, cloudy urine, and behavior changes .
The care plan also included the resident's use of indwelling urinary catheter needed due to urinary
retention and history of prostate cancer with interventions to change urinary collection bag as needed and
change catheter per physician order.
Review of the laboratory test for urine culture dated 4/27/21 indicated the resident was positive for
pseudomonas aeruginosa (bacteria).
Review of the electronic treatment record (TAR) revealed catheter change was not completed per orders
and there was no documentation for catheter care.
On 05/19/21 at 10:08 AM, the Assistant Director of Nursing (ADON) stated that the resident was not
admitted with a Foley catheter, but due to retention an order was obtained for the indwelling catheter. She
added that for residents with a Foley catheter, staff are supposed to complete catheter care and document
in the TAR. When asked about Resident #63's catheter care, she confirmed that there was no
documentation for catheter care. She also confirmed that the order for catheter change was not completed
on 5/14/21. The ADON continued to state that resident had just completed antibiotic prescription due to
UTI.
In an interview on 05/19/21 at 11:48 AM , Employee C , Certified Nursing Assistant (CNA) stated that care
is provided every shift by the CNAs and the nurses are supposed to check. When asked if she had received
any training on catheter care she stated that none was provided at this facility.
On 05/19/21 at 02:21 PM, the Director of Nursing (DON) was asked the expectation for Foley catheter
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 3 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
care. She stated that the facility protocol was for staff to clean the catheter with soap and water every shift.
She confirmed that residents with Foley catheter orders were not updated in the TAR; therefore it was not
clear if care was provided. She also confirmed that the catheter for Resident #63 was not changed per
physician order.
Residents Affected - Few
Review of the policy and procedure titled catheter care: indwelling catheter revealed the following:
Suggested documentation :
Care provided in POC including task completion.
Create a new alert in POC creating a custom alert if required for unusual observation.
Care provided in progress notes including reaction to procedure, color and amount of urine, and usual
observation and/or complaint and subsequent interventions including communications with the medical
practitioner as clinically indicated.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 4 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an
interview with Resident #73 on 5/16/2021 at 4:25 PM, the oxygen tubing with nasal cannula was observed
on the floor unbagged and not in use. The resident placed the cannula on and turned on the concentrator
during the interview. It was observed to be set at 3.5 liters per minute (lpm). (Photographic evidence
obtained)
Residents Affected - Some
During a second observation on 5/18/2021 at 8:30 AM, Resident #73 was using her oxygen at 3 lpm. She
stated she didn't know her order and guessed it was between 2 and 3 lpm. (Photographic evidence
obtained)
Record review of Resident #73's orders showed she was ordered oxygen at 2 lpm via nasal cannula every
shift for COPD, written at admission on [DATE]. On 5/17/2021 it was rewritten for 2 lpm as needed, for
saturations below 92%. (Photographic evidence obtained)
A note authored in the electronic chart for Resident #73, dated 4/23/2021, also explained she was to use
oxygen at 2 lpm. On 05/05/2021 a note stated, Patient is alert and responsive able to make needs known.
On Oxygen at 3 LPM via nasal cannula.
Employee B, LPN, confirmed at 10:46 AM on 5/18/2021 that Resident #73's oxygen order was for 2 lpm.
During a third observation at 10:49 AM on 5/18/ 2021, Resident #73's nurse, Employee B, was present and
confirmed she was using her oxygen at 3 lpm.
Based 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.
The findings include:
1. On 5/17/2021 at 1:44 pm, Resident #187 was observed in her room with nasal cannula present and an
oxygen concentrator administering oxygen at .5 liters per minute.
On 5/18/2021 at 10:45 am, Resident #187 was observed in her room sitting in a wheelchair with nasal
cannula present. The the oxygen concentrator was administering oxygen at 1 liter per minute.
Record review for Resident # 187 revealed that she was admitted to the facility on [DATE]. Her diagnoses
included type 2 diabetes mellitus; dysphagia; unspecified dementia without behavioral disturbance; acute
respiratory failure with hypoxia; essential hypertension; anxiety disorder; arteriosclerotic heart disease of
native coronary artery; other nonspecific finding abnormal finding of lung field; and major depressive
disorder.
Physician orders included Oxygen at 3 liters per minute via nasal cannula every shift.
Per the admissions Minimum Data Set completed on 5/10/2021, Resident #187 required limited assistance
with personal hygiene and extensive assistance with eating, toilet use, bed mobility, transfers
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 5 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
and dressing. She required oxygen while residing in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Review of the care plan, dated 5/4/2021 revealed: Focus: the resident has altered respiratory status related
to respiratory failure with hypoxia; Goal: the resident will have no shortness of breath; Intervention includes:
provide Oxygen as ordered.
Residents Affected - Some
Per nurses progress notes, on 5/5/2021 a new order was received for oxygen at 3 liters per minute via
nasal cannula.
During an interview on 5/18/2021 at 10:45 am with Employee D, a Licensed Practical Nurse (LPN)
Supervisor, she stated that she was familiar with Resident #187. She confirmed that Resident #187 had an
order for Oxygen via nasal cannula at 3 liters per minute. She stated that the nurses are responsible for
oxygen care which included patient positioning, ensuring the proper placement of the nasal cannula and
the accuracy of the settings based on the orders each shift.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 6 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based 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.
The findings include:
During a record review of Resident #54's chart, the physician orders showed he was ordered Paxil for
depression and Seroquel for a psychotic disorder.
Resident #54's electronic record contained an assessment titled Medication Regimen Review dated
08/03/2020 which contained pharmacy recommendations for the Paxil. The Pharmacist recommended a
change from 20 mg to 10 mg at that time. The associated progress note contained the same information,
but neither included information that these recommendations were sent to a physician for review. A paper
note from the resident's psychiatric APRN showed that on 09/01/2020, Resident #54 was on 25 mg of
Seroquel twice a day and 20 mg of Paxil once a day. Page 3 of this note stated he was on a trial dose
reduction of both medications. The note from 09/28/2020 had the same information on the resident's dose
and gradual dose reduction (GDR) status. (Photographic evidence obtained) No notes were presented past
September 2020. All the notes presented contained language the resident was undergoing a trial GDR, but
a review of the physician orders negated this comment.
Review of the physician orders in the electronic medical record confirmed the Paxil was changed from 20
mg to 10 mg on 5/18/2021. Prior to this adjustment, he was on 20 mg of Paxil since 02/14/2020. His current
Seroquel dose of 25 mg twice a day was ordered 04/07/2020. (Photographic evidence obtained)
On 5/19/2021 at 10:01 am Employee A, LPN, stated the resident's Paxil was just adjusted on 05/18/2021
from 20 mg to 10 mg, and the Seroquel (25 mg) was given twice a day since 04/07/2020.
During a review of the Medication Regimen Review (MRR) binder for the facility, there was also a
recommendation made for Resident #54 dated 01/21/2021 which requested the Paxil be reduced to 10 mg
from 20 mg as a trial gradual dose reduction (GDR). Handwritten on this recommendation from the
Pharmacist was a marking to accept the GDR, signed and dated 4/21/21 by the resident's physician.
(Photographic evidence obtained )
There were no additional paper recommendations in the MRR book which were signed by residents'
physicians; this was previously explained by the Director of Nursing (DON) at 9:38 AM on 5/19/2021, who
explained the previous DON did not maintain these records. She explained she was going to have the
Pharmacist email her his recommendation letters which were missing from the MRR book.
These emails were presented and upon further review, none of the recommendations contained signature
and acceptance/rejection of the Pharmacist's recommendation since they were just emailed and printed off
during the survey. The unacknowledged paper MRRs were for a span of May 2020 to November 2020.
Review of the hard chart for Resident #54 kept at the nurse's station showed no more additional
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 7 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
pharmacy recommendation letters for the Paxil. The emailed MRRs from the Pharmacist were reviewed and
a hard copy of a recommended GDR for the Seroquel was issued to the facility on 7/20/2020. It did not
contain a signature or any indication the physician reviewed this recommendation and accepted or rejected
it. (Photographic evidence obtained) There was no information in the progress notes of the electronic record
to indicate a physician reviewed the recommendation.
Residents Affected - Few
During an interview with the DON at 8:21 AM on 5/20/2021, she confirmed Resident #54 received 20 mg of
Paxil from February 2020 to May 2021. She again confirmed they could not locate any MRR
recommendations which were signed off by a physician from May to December 2020 and only had the print
outs which were emailed to her this week, which did not show a physician was given the recommendation
to review. At 11:35 AM on 5/20/2021, she confirmed the notes from the visiting psych APRN did not match
what was actually being given to Resident #54 and he was not actually undergoing a GDR as the note
read.
A follow up interview was conducted with the DON on 5/20/21 at 12:38 PM. She reviewed the last year's
worth of notes from Resident #54's visiting physician and confirmed he did not address the pharmacist's
recommendations within the progress notes either. Upon review of the visit notes from May 2020 to present,
there was no indication the physician addressed the GDR recommendations within his own progress notes.
(Photographic evidence obtained
Review of the policy contained within the MRR book showed the following process for GDR
recommendations (dated 2018): The Consultant Pharmacists perform MRR for patients and will generate
recommendations with the overall goal of promoting positive outcomes and minimizing adverse
consequences. To ensure MRR recommendations are addressed timely, the DON or designee reviews the
MRR and contacts the attending physician to review and obtain orders as warranted. The DON or designee
documents on the MRR and in the patient's clinical record the physician's orders and forwards the
completed MRR to the DON within 30 days of the review. The attending physician documents the review
and any resulting actions or orders on the MRR. New orders may be generated on physician orders.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 8 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
Record review for Resident #54 revealed physician orders for Paxil for depression and Seroquel for a
psychotic disorder. On 5/19/2021 at 10:01 am Employee A, LPN, stated his Paxil was just adjusted on
5/18/2021 from 20 mg to 10 mg.
Review of the physician orders in the electronic medical record confirmed the Paxil was changed from 20
mg to 10 mg on 5/18/2021. Until this change, he had been on Paxil 20mg since 02/14/2020. (Photographic
evidence obtained)
During a review of the assessment dated [DATE] within the electronic record titled Medication Regimen
Review (MRR) for Resident #54, the Pharmacist recommended the Paxil be reduced to 10 mg (from 20 mg)
as a trial gradual dose reduction (GDR). The facility also had paper recommendation forms on this MRR,
and there was a handwritten marking to accept the GDR, signed and dated 4/21/21 by Resident #54's
physician. (Photographic evidence obtained)
There were no additional paper recommendations in the MRR book which were signed by residents'
physicians. This was previously explained by the Director of Nursing (DON) at 9:38 AM on 5/19/2021, who
indicated the previous DON did not maintain these records. She explained she was going to have the
Pharmacist email her his recommendation letters which the facility had been unable to locate.
During an interview with the DON at 8:21 AM on 5/20/2021, she confirmed Resident #54 received 20 mg of
Paxil from February 2020 to May 2021. The paper MRR was reviewed and she confirmed the excessive
length of time it took the physician to sign off on the review (3 months), and that the resident only started
getting the reduced dose this week, 4 months after the GDR recommendation and 1 month after the
physician signed off on it.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 9 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based 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.
The findings include:
On May 20, 2021 at 10:00 am, Employee E was asked to show the medication room where their Omni Cell
Automated Medication Dispensing System (AMDS) was located. Employee E asked Employee D to show
the surveyor where the AMDS was kept. Both Employees D and E escorted the surveyor to a room across
from the Med-Bridge nurses station area which had a sign next to the door that said Doctors Lounge. The
door to this room was open. It was observed that the door handle had a 5 digit push lock system. It was
observed that the door latch was taped down with paper surgical tape in such a fashion that the latch would
not engage with the door frame if closed. The AMDS was observed inside this room.
Employee D was asked if this door was always kept open. She replied, To be honest, I've never seen this
door closed, unless a doctor is in here dictating. Both Employees D and E were asked if they knew the code
to the 5 digit push lock system on the door. They both replied no, they did not know the code to gain access
to that door lock system.
Employee D was asked if the AMDS contained narcotic medications. She stated Yes. The machine contains
all the IV supplies and medications we might need for a new admission, or for if a doctor wrote a new order,
so we can get the medication started right away, while we are waiting for the pharmacy to deliver the
medications ordered. Or if we run out of something that was ordered, but we are still waiting for the delivery,
we can access those meds in the machine.
Review of the Omni Cell AMDS contents list found 14 different schedule II-V medications listed.
A review of facility policy/procedure titled 5.3 Storage and Expirations of Medications, Biologicals, syringes
and Needles (effective date 12/1/07, revised 5/10/10, 1/1/13, and 10/31/16) states:
3. General Storage Procedures:
3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be
at risk for abuse or diversion in a separate compartment within the locked medication carts and should
have a different key or access device.
17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a
regularly scheduled basis.
A review the facility policy and procedure titled Medication and Treatment Administration Guidelines
(7/2002, revised 3/2018) states:
Medication Storage and Security:
- Controlled substances are securely stored using a double lock system (medication cart, medication
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 10 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105366
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vivo Healthcare University
3648 University Blvd S
Jacksonville, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
room, refrigerator, controlled substance lock box, and/or separately keyed controlled substance drawer in
medication cart)
Level of Harm - Minimal harm
or potential for actual harm
- Only licensed nursing staff have key access to medication storage area.
Residents Affected - Few
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105366
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the May 20, 2021 survey of VIVO HEALTHCARE UNIVERSITY?
This was a inspection survey of VIVO HEALTHCARE UNIVERSITY on May 20, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VIVO HEALTHCARE UNIVERSITY on May 20, 2021?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.