Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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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What surveyors actually found near you
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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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Illustrative
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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 | ★★★★★ | 8 | 0 |
| Rose Haven Retreat | 19.8 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.