Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vivian Healthcare Center during CMS and state inspections, most recent first.
Failure to Provide Advance Directive Information: The facility did not provide or document written Advance Directive information for 5 of 5 residents reviewed. Records for residents with diagnoses including dementia, CHF, COPD, CKD, stroke sequelae, and Alzheimer’s disease lacked evidence that the resident or RP was informed of the right to formulate an AD, and staff confirmed the acknowledgments had not been completed.
Unnecessary psychotropic medication use was not ensured for 3 residents. One resident with Parkinson's disease, MDD, and dementia had a Seroquel GDR recommendation that was not implemented, and three residents had PRN psychotropic orders that continued beyond 14 days without a documented rationale or stop date. The DON confirmed the missing GDR documentation and extended PRN orders.
A facility failed to provide written bed hold and appeal notices to three residents transferred to the hospital, including residents with acute respiratory failure, CKD, COPD, dementia, and other chronic conditions. The facility also did not update the Ombudsman emergency transfer log for two residents, and staff interviews confirmed the missing documentation and notifications.
The facility failed to include side rail assist bars in the care plans of four residents, despite physician orders and observations confirming their use. These residents, with various medical conditions such as Parkinson's, dementia, and hemiplegia, required these assist bars for bed mobility and transfers. However, their comprehensive care plans lacked focus and appropriate interventions for the use of these devices, as confirmed by facility staff.
A resident requiring dialysis did not receive proper post-treatment assessments at the facility. Despite physician orders for monitoring the AV shunt site and obtaining vital signs, the resident reported that these were not conducted, and they had to remove their own dressing. Staff interviews revealed a lack of consistent assessment and communication regarding the resident's return from dialysis, with the DON unaware of any policy for such assessments.
A facility failed to follow protocols for bed rail use by not obtaining a physician order, informed consent, or updating the care plan for a resident with epilepsy and dementia. The resident had side rail assist bars installed without proper documentation or consent, as confirmed by the DON.
A facility failed to notify a resident's physician and responsible party of a change in condition following an investigational incident. Despite the facility's policy requiring such notifications, there was no documentation of informing the physician or responsible party. The resident, with multiple mental health diagnoses and moderate impairment, was involved in an incident reported to the state, but the necessary notifications were not made.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to inform residents or their representatives and provide written information about the right to formulate an Advance Directive for 5 of 5 residents reviewed for Advance Directives. The facility policy stated that, upon admission, residents are to be provided written information concerning the right to refuse or accept medical treatment and to formulate an Advance Directive, including a description of the facility’s policies and applicable state law. The policy also stated that if a resident is incapacitated, the information may be provided to the resident’s legal representative. Review of Resident #4’s record showed an admission date of 03/28/2023 and diagnoses including COPD, CHF, hypertensive CKD, atherosclerotic heart disease, dementia, and anxiety disorder. The medical record did not reveal consent or education materials for Advance Directives given to the resident or responsible party upon admission. During interview, the Interim Assistant Administrator confirmed Resident #4 did not have a completed Advance Directive form indicating written materials had been provided. Resident #5, Resident #10, Resident #36, and Resident #53 also had no documentation in their records showing that Advance Directive materials were provided to the resident or resident’s representative upon admission. Resident #5 had diagnoses including aftercare following joint replacement surgery, displaced fracture of the right femur neck, weakness, gait and mobility abnormalities, and unspecified dementia; Resident #10 had sequelae of cerebral infarction, left-sided hemiplegia/hemiparesis, diabetes with polyneuropathy, COPD, CKD stage 3, and ileostomy care; Resident #36 had diagnoses including spondylosis, emphysema, type 2 diabetes with CKD, apraxia following intracerebral hemorrhage, carotid artery occlusion and stenosis, heart disease, TIA history, and cerebral infarction without residual deficits; and Resident #53 had Alzheimer’s disease, dementia, and major depressive disorder. Interviews with facility staff confirmed the Advance Directive acknowledgments had not been obtained or completed for these residents.
Unnecessary Psychotropic Medication Orders and Missed GDR
Penalty
Summary
Preventing the use of unnecessary psychotropic medications was not ensured for 3 of 5 residents reviewed for unnecessary medications. Resident #9 had diagnoses including Parkinson's disease, major depressive disorder, and dementia, and was ordered Quetiapine 12.5 mg twice daily for major depressive disorder. The record showed a GDR recommendation on 01/14/2026 to decrease Seroquel to 12.5 mg once at night, but review of completed and discontinued orders from 01/14/2026 through 05/11/2026 did not show that the recommended reduction was implemented. The DON confirmed there was no documentation of a GDR attempt or a rationale for not attempting the reduction. Resident #9 also had a PRN order for Hydroxyzine 25 mg every 6 hours as needed for anxiety and/or itching that began on 11/18/2023, and the record did not show a rationale or stop date for continuing the PRN psychotropic order beyond 14 days. Resident #13, admitted with unspecified dementia, anxiety disorder, and altered mental status, had a PRN Lorazepam 0.5 mg order for agitation related to anxiety disorder that began on 10/13/2025, with no rationale or stop date documented. Resident #53, admitted with Alzheimer's disease, unspecified dementia, and major depressive disorder, had a PRN Hydroxyzine Pamoate 50 mg order for anxiety that began on 01/15/2026, and the record also lacked a rationale or stop date. The DON confirmed these PRN psychotropic medication orders lasted longer than 14 days without a stop date or rationale for the extended orders.
Missing bed hold notices and Ombudsman transfer log entries
Penalty
Summary
The facility failed to provide written notice to residents and/or their responsible parties that included the reason for transfer, the effective date, the location, appeal rights, and the duration of bed hold for 3 residents reviewed for hospitalizations. Resident #6, admitted with acute respiratory failure with hypoxia and dependence on renal dialysis, had multiple emergency transfers to an acute care hospital, but the record did not show written bed hold notification was given at the time of those transfers. Resident #10, admitted with diagnoses including sequelae of cerebral infarction, diabetes mellitus with diabetic polyneuropathy, COPD, and CKD, was sent to the hospital per request and returned to the facility, but the record did not show bed hold notification was provided at the time of transfer. Resident #56, admitted with CKD and unspecified dementia, was transferred to an acute care hospital, and the record did not show written notification of the facility's bed hold policies was given to the resident's RP at the time of transfer. The facility also failed to update the emergency transfer log, identified as the Notice of Discharge to the Ombudsman, for 2 of the 3 residents reviewed for hospitalizations. Review of the Ombudsman Emergency Transfer Log for 04/01/2025 through 03/31/2026 did not show documentation that the Ombudsman was notified of Resident #6's transfer to the hospital on [DATE] or Resident #10's transfer on [DATE]. During interviews, the Business Office Manager, Social Services, DON, Corporate Nurse, and Regional Operation Manager/Interim Administrator stated there was no documentation of the bed hold policy/notification at transfer for Residents #6, #10, and #56, and Social Services confirmed the Ombudsman was not notified of the transfers for Residents #6 and #10 and should have been.
Failure to Include Side Rail Assist Bars in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents regarding the use of side rail assist bars, as required by their policy on Personal Safety Devices. The policy mandates evaluation, notification, orders, care planning, and routine monitoring for devices like side rail assist bars. However, the care plans for Residents #13, #37, #50, and #52 did not include a focus or appropriate interventions for the use of these assist bars, despite physician orders and observations confirming their use. Resident #13, diagnosed with Parkinson's and dementia, had a physician order for side rail assist bars to aid in bed mobility and transfers. Observations confirmed the use of these bars, and the resident reported using them for repositioning and getting out of bed. However, the comprehensive care plan lacked any mention of these assist bars. Similarly, Resident #37, with hemiplegia following a cerebral infarction, also had a physician order for side rail assist bars, but their care plan did not address this need. Resident #50, with severe cognitive impairment and a history of cerebral infarction, required supervision for transfers and had a physician order for side rail assist bars. Observations confirmed the use of these bars, yet the care plan did not include them. Resident #52, with spinal stenosis and dorsalgia, also had a physician order for side rail assist bars, but their care plan failed to address this. Interviews with facility staff confirmed the absence of appropriate care planning for these devices, highlighting a systemic issue in care plan development for these residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. Resident #37, who was cognitively intact with a BIMS score of 12 out of 15, had physician orders for dialysis three times a week and specific instructions for monitoring the AV shunt site for signs of infection and excessive bleeding. However, upon return from dialysis, the resident reported that the nursing staff did not assess the dialysis access site or obtain vital signs, and the resident had to remove their own dressing. An observation confirmed that the resident's dialysis access site had no dressing in place. Interviews with facility staff revealed a lack of consistent assessment and communication regarding the resident's return from dialysis. S5 RN admitted that assessments and vital signs were only conducted if the resident complained of feeling unwell, and there was no clear communication from the transport driver about the resident's return. Furthermore, the Director of Nursing (S2 DON) acknowledged that the nursing staff should complete a dialysis checklist and obtain vital signs upon the resident's return, but was unaware of any existing policy for such assessments. This lack of adherence to professional standards of practice led to the deficiency in providing safe and appropriate dialysis care for Resident #37.
Failure to Follow Protocols for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use of bed rails for a resident, as evidenced by the absence of a written physician order for side rail assist bars, lack of informed consent from the resident or their responsible party prior to installation, and failure to initiate a care plan with a focus on side rail assist bars. The facility's policy requires evaluation, notification, an order, care planning, and routine monitoring for devices like side rails, but these steps were not followed for the resident in question. The resident, who was admitted with diagnoses including intractable epilepsy, dementia, and mild cognitive impairment, had side rail assist bars installed without a physician's order or a care plan focus on the use of these devices. An informed consent was obtained verbally after the installation, rather than prior, as required. The Director of Nursing confirmed these oversights during an interview, acknowledging that the necessary procedures were not followed.
Failure to Notify Physician and Responsible Party of Incident
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a change in condition following an investigational incident. The facility's Abuse Prohibition Policy, reviewed on 05/17/2024, mandates notification to the attending physician and family during an investigation. However, a review of the medical record for a resident with diagnoses including major depressive disorder, delusional disorder, schizoaffective disorder, unspecified dementia, cognitive communication deficit, and behavioral disturbance, revealed no documentation of such notifications. The resident, who was moderately impaired with a BIMS score of 3, was involved in an incident reported to the state office on 09/03/2024, yet the physician and responsible party were not informed. This oversight was confirmed during an interview with the facility's administrator on 09/25/2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Vivian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Villa | 19.7 mi | ★★★★★ | 9 | 0 |
| Rose Haven Retreat | 19.8 mi | ★★★★★ | 7 | 0 |
| Avir At Jefferson | 22.6 mi | ★★★★★ | 16 | 0 |
| Old Brownlee Community Care Center | 23.8 mi | ★★★★★ | 0 | 0 |
| Cypress Point Nursing & Rehabilitation Center | 24.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.