Vivian Healthcare Center

Based on record review and an interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an Advance Directive for 5 (#4, #5, #10, #36, and #53) of 5 residents reviewed for Advanced Directives. Findings: Review of facility's Advance Directive Policy with latest revision date of August 2023 revealed in part;Policy Statement: Advance Directives will be respected in accordance with state law and facility policy.Policy Interpretation and Implementation:Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an Advanced Directive if he or she chooses to do so.2. Written information will include a description of the facility's policies to implement Advance Directives and applicable state law.3. If the resident is incapacitated and unable to receive information about his or her right to formulate an Advance Directive, the information may be provided to the resident's legal representative. 6. Prior to or upon…

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 record reviews and interviews, the facility failed to ensure 3 (#9, #13, and #53) of 5 residents reviewed for unnecessary medications were free from chemical restraints by failing to: ensure Resident #9's GDR recommendations were implemented andensure Residents' (#9, #13, and #53) orders for PRN psychotropic medications did not exceed 14 days without a rational. Findings: Review of the facility's Psychotropic/Psychoactive Medication Policy revised 01/2025 revealed in part: Policy StatementA psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (I) Antipsychotic; (II) Anti-depressant; (III) Anti-anxiety; and (IV) Hypnotic. Other medications which affect brain activity will also be subject to psychotropic medication requirements if documented use is a substitution for a psychotropic medication rather than the approved or original indication.Psychotropic medications are used only when appropriate and at the lowest possible dose to enhance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to: 1. Provide written notice to residents and/or their RP which specified the reason for transfer, effective date, location and statement of the resident's appeal rights and duration of the bed hold for 3 (#6, #10, and #56) of 3 residents reviewed for hospitalizations, and 2. Update the emergency transfer log (Notice of Discharge to the Ombudsman) for 2 (#6 and #10) of 3 residents reviewed for hospitalizations. Findings: Resident #6 Review of Resident #6's medical record revealed an admission date on 11/21/2025 and diagnoses including acute respiratory failure with hypoxia and dependence on renal dialysis. Review of Resident #6's medical record revealed emergency transfers to an acute care hospital on [DATE], 12/16/2025, 03/05/2026, 03/31/2026 and 04/18/2026. Further review failed to reveal documentation Resident #6 or Resident #6's RP was given written notification of the facility's bed hold policies at the time of his transfer's to the hospital on…

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 reviews, observations, and interviews the facility failed to ensure a plan of care had been developed for 4 (#13, #37, #50, #52) of 8 (#13, #18, #32, #37, #38, #50, #52, #168) residents reviewed for accidents. The facility failed to ensure a plan of care for side rail assist bars had been developed for Residents #13, #37, #50, and #52. Findings: Review of the facility's PSDs (Personal Safety Devices)-Enablers-Side Rails & Restraints policy with a revision date of February 2025 revealed in part, these devices require evaluation, resident and/or responsible party notification, an order, care planning, and routine monitoring for effectiveness and restraining effect. Resident #13 Review of Resident #13's medical record revealed in part, an original admission date of 03/01/2011 with diagnoses including, but not limited to Parkinson's without dyskinesia and dementia with agitation. Review of Resident #13's annual and state MDS (Minimum Data Set) assessments dated 12/13/2024 revealed in part, a BIMS…

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, observation, and interviews, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#37) of 1 resident reviewed for dialysis by failing to assess Resident #37 upon return to the facility from dialysis treatment. Findings: Review of Resident #37's March 2025 physician orders revealed: 01/22/2025: Resident to receive dialysis 3 days a week on Monday-Wednesday-Friday at ____ dialysis center. 12/05/2025: Monitor AV (Arteriovenous) shunt pressure dressing to left arm for excessive bleeding every shift upon return from dialysis and remove dressing morning after dialysis. 12/05/2025: Monitor AV shunt site left arm for signs and symptoms infection q (every) shift. Palpate pulse(s) distal to shunt. Note changes in skin color and temp. Report changes to physician. 12/05/2025: AV shunt to left arm. Assess & palpate AV shunt q shift for thrill and bruit. Report concerns to physician. Review of Resident #37's…

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, observation, and an interview, the facility failed to ensure correct use of bed rails as evidence by failing to obtain a written a physician order for side rail assist bars, obtain an informed consent from resident or resident's responsible party prior to installation, and ensure a care plan was initiated with a focus for side rail assist bars for 1 (#168) out of 8 (#13, #18, #32, #37, #38, #50, #52, and #168) residents investigated for accidents. Findings: Review of the facility's PSDs (Personal Safety Devices) -Enablers-Side Rails & Restraints Policy with a revision date of February 2025 revealed in part, These devices require evaluation, resident and/or responsible party notification, an order, care planning, and routine monitoring for effectiveness and restraining effect. Protocols for PSD-Enablers-Side Rails and Restraints I. When a resident is admitted with or is prescribed a personal safety, enabler and/or a type of side rail. The IDT (Interdisciplinary Team) will: notify resident…

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 record reviews and interviews the facility failed to ensure the resident's physician and RP (Responsible Party) were notified of a change in condition for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for resident rights. The facility failed to notify Resident #1's physician and RP when Resident #1 was involved in an investigational incident. Findings: Review of the facility's Abuse Prohibition Policy with a reviewed date of 05/17/2024 revealed in part: Policy and Procedures. Investigation . 6.) Procedure for the investigation will include, but is not limited to the following: Notification to the attending physician and family. Review of Resident #1's medical record revealed an admission date of 11/02/2021 with a readmission date of 12/14/2023. Review of Resident #1's medical record revealed the following diagnoses in part: Major depressive disorder, delusional disorder, schizoaffective disorder, unspecified dementia, cognitive communication deficit, and behavioral disturbance. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 08/01/2024 revealed a…

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 observations, interviews and record reviews the facility failed to ensure necessary care and services were provided in accordance with accepted professional standards of practice for 2 (#37, #54) of 2 (#37 and #54) residents reviewed for respiratory care. The facility failed to ensure equipment was assembled correctly by not having a humidifier bottle attached to the oxygen concentrators. Findings: Review of the facility's Oxygen Administration Procedure revealed in part the following: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand); 2. Nasal cannula, nasal catheter, mask (as ordered); 3. Humidifier bottle; 4. No smoking/Oxygen in Use signs: Steps in the Procedure: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough…

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 interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#58) out of 29 sampled residents reviewed. The facility failed to enter an accurate discharge status for Resident #58. Findings: Review of resident #58's electronic medical record revealed an admission date of 06/14/2019 and a discharge date of 12/08/2023. Review of resident #58's MDS dated [DATE] revealed a (planned) discharge with return not anticipated to a short-term General Hospital. Review of resident #58's discharge summary revealed the resident was discharged to another long-term care facility with a family member. During an interview on 02/20/2024 at 3:15 p.m. S2LPN (Licensed Practical Nurse) indicated resident #58 was discharged to another long term care facility at her family's request. During an interview on 02/20/2024 at 3:22 p.m. S3MDS Nurse confirmed resident #58's discharge MDS of 12/08/2023 was coded as a hospitalization and should have been coded as a transfer to another…

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 record reviews and an interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#54) of 21 (#1, #4, #6, #8, #14, #16, #17, #18, #24, #27, #28, #37, #39, #41, #44, #46, #49, #53, #54, #58 and #59) sampled resident's care plans reviewed. The facility failed to monitor resident #54's oxygen saturation level every shift as ordered by the physician/NP (nurse practitioner). The facility failed to have a physician order for oxygen therapy. Findings: Review of resident #54's medical records revealed she was admitted to this facility on 09/23/2023. Resident #54 had multiple diagnoses that included acute chronic diastolic congestive heart failure, acute pulmonary edema, other sequelae of cerebral infarction and dementia. Review of resident #54's physician/NP Progress notes dated 02/06/2024 revealed she was seen and evaluated on this date due to staff reported resident with increased cough and shortness of breath. Resident recently had an inpatient hospitalization for CHF (Congestive Heart Failure) exacerbation with pneumonia. 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 record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 10 of 25 weekend days reviewed. Findings: Review on the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 to March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 2 2023 revealed the facility provided 127.81 hours on 02/11/2023 and were required to provide 133.95 hours, provided 124.59 hours on 02/12/2023 and were required to provide 131.60 hours, provided 146.91 hours on 02/18/2023 and were required to provide 148.05 hours, provided 143.83 hours on 02/19/2023 and were required to provide 145.70 hours, provided 131.95 hours on 02/25/2023 and were required to provide 141 hours, provided 127 hours on 03/05/2023 and were required to…

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.