Inspection Reports for
Vaiden Community Living Center
868 Mulberry Street, Vaiden, MS, 39176
Back to Facility Profile45 Reports
Inspection Report — Aug 18, 2026
Complaint Investigation
Date: Aug 18, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3103963 and CI MS #3166196) at the facility from 08/17/26 through 08/18/26. The facility was found not in compliance with Medicare and Medicaid requirements related to accidents and notification of family.
Complaint Details
Two complaint investigations (CI MS #3103963 and CI MS #3166196) were conducted. Deficiencies were cited related to accidents and notification of family for Resident #2, who suffered a fall with major injury during a transfer using a mechanical lift without required assistance.
Findings
The facility failed to ensure a resident was free from accident hazards during a transfer using a mechanical lift which resulted in a fall with major injury. The facility also failed to immediately notify the resident representative of the accident and resulting injury.
Deficiencies (2)
F0689 - Free of accident hazards and adequate supervision. The facility failed to ensure Resident #2 was transferred safely using a mechanical lift with required assistance, resulting in a fall and major injury.
F0580 - Notification of changes. The facility failed to promptly notify Resident #2's representative of the fall and resulting major injury.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 17, 2026
Follow-Up
Date: Aug 17, 2026
Visit Reason
On 08/17/26 the State Agency (SA) conducted an onsite revisit related to the annual survey that was completed on 06/30/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation as of 08/05/26. However, the facility remained out of compliance due to Life Safety Code (LSC) deficiencies until 08/06/26. The SA is recommending that your facility be placed back in compliance effective 08/06/26.
Findings
The revisit confirmed the facility had corrected the previously cited deficiencies and sustained compliance with Medicare and Medicaid requirements as of 08/05/26. The facility was recommended to be placed back in compliance effective 08/06/26.
Inspection Report — Aug 6, 2026
Life Safety
Date: Aug 6, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual survey conducted on 06/30/26. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The survey conducted on 06/30/26 revealed the facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Jun 30, 2026
Annual Inspection
Date: Jun 30, 2026
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 06/28/26 through 06/30/26. During the survey, the facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies.
Findings
The facility was found not in compliance with several requirements including food safety, reasonable accommodations for a visually impaired resident, resident group meeting consistency, quality of care related to medical evaluations, and infection prevention and control practices.
Deficiencies (5)
F0812 - Food procurement, storage, preparation, and serving were not sanitary. Observations included uncovered dry bins, spoiled bread, improper food handling such as placing a dropped sandwich back on a tray, and serving food contaminated by a fly.
F0558 - The facility failed to provide reasonable accommodation for a visually impaired resident by not consistently ensuring access to a call system that accommodated the resident's disability despite complaints.
F0565 - The facility failed to ensure consistent monthly Resident Council meetings, cancelling the May 2026 meeting without rescheduling or resident consent.
F0684 - The facility failed to perform a necessary Hemoglobin A1c test for a diabetic resident as ordered by the physician, missing the April 2026 test.
F0880 - The facility failed to follow infection prevention and control practices by not performing hand hygiene between glove changes during wound care for a resident, risking infection transmission.
Report Facts
Deficiencies cited: 5
Inspection Report — Jun 30, 2026
Annual Inspection
Date: Jun 30, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 06/28/26 through 06/30/26. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M815 and M1570.
Findings
The facility was found not in compliance with state licensure requirements due to unsafe food handling practices and failure to follow infection control standards during wound care.
Deficiencies (2)
M0815 - Safe Food Handling Procedures. The facility failed to store and serve food in accordance with professional standards, including uncovered dry bins, food contamination from a sandwich dropped on the floor and replaced, improperly stored bread with mold, and serving food with a fly present.
M1570 - Infection Control. The facility failed to perform hand hygiene between glove changes during wound care for one resident, increasing risk of infection transmission.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 29, 2026
Life Safety
Date: Jun 29, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
One deficiency was cited related to the electrical systems essential electric system alarm. The facility failed to provide a working generator annunciator panel affecting all 56 residents.
Deficiencies (1)
K0916 - Electrical Systems - Essential Electric System Alarm. The facility failed to provide all required generator components, including a nonworking generator annunciator panel observed on 6/30/26.
Report Facts
Deficiencies cited: 1
Inspection Report — May 11, 2026
Complaint Investigation
Date: May 11, 2026
Visit Reason
On 05/11/26 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 03/24/26. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 03/24/26; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 05/05/26. No deficiencies were cited in this document.
Inspection Report — Mar 24, 2026
Complaint Investigation
Date: Mar 24, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS# 2704158 and CI MS# 2708040) at the facility on 3/24/26. The facility was found non-compliant for CI MS# 2708040 related to a discharge; no deficiencies were cited for CI MS# 2704158.
Complaint Details
Two complaint investigations were conducted (CI MS# 2704158 and CI MS# 2708040). Deficiency F0627 was cited for CI MS# 2708040 related to an inappropriate discharge. No deficiencies were cited for CI MS# 2704158.
Findings
The facility failed to provide written notice of an involuntary discharge including appeal rights prior to refusing readmission from the hospital for one resident (Resident #1). The Administrator confirmed the absence of a formal discharge notice, appeal rights, and a physician order for discharge.
Deficiencies (1)
F0627 - Inappropriate discharge. The facility failed to provide written notice of an involuntary discharge including appeal rights prior to refusing readmission from the hospital for one resident (Resident #1).
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 18, 2025
Complaint Investigation
Date: Aug 18, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2581280, at the facility on 08/18/25, related to resident rights.
Complaint Details
CI MS #2581280 related to resident rights; the complaint was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The inspection was conducted following a complaint and incident involving Resident #1 who was injured during transport in the facility van when staff failed to properly secure the wheelchair, resulting in a fall and injuries.
Complaint Details
The complaint investigation was substantiated. Resident #1 was injured during transport on 4/28/25 due to improper wheelchair securement by staff. The resident sustained multiple injuries and later passed away due to unrelated acute renal failure. The facility took corrective actions including staff termination and safety training.
Findings
The facility failed to ensure the safety of Resident #1 during transport by not properly securing the wheelchair, causing the resident to sustain a sternal fracture and head lacerations. The responsible staff member was terminated, and corrective actions including van safety in-service and monitoring were implemented prior to the survey.
Deficiencies (1)
F 0689: The facility failed to ensure the safety of one resident during transport by not properly securing the wheelchair with safety belts, resulting in the resident sustaining a sternal fracture and head lacerations. The responsible staff member was terminated for not following facility policy.
Report Facts
Date of incident: Apr 28, 2025
Length of scalp laceration: 3
Length of second laceration: 2
Date of death: May 3, 2025
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA #1) | Van driver who failed to properly secure wheelchair, resulting in resident injury and was terminated | |
| Administrator (ADM) | Interviewed regarding incident and facility corrective actions | |
| Director of Nursing (DON) | Involved in investigation and corrective action monitoring | |
| Maintenance Director | Inspected van after incident and confirmed safety equipment was not used properly | |
| Certified Nurse Assistant (CNA #2) | Demonstrated proper wheelchair securement during transport of other residents |
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28771 and CI MS #29261). CI MS #28771 was for a self-reported incident of a resident fall inside the facility van on 4/28/25, and CI MS #29261 was for an anonymous report of a sick child being brought to work with a staff member.
Complaint Details
CI MS #28771 involved a self-reported incident of a resident fall inside the facility van on 4/28/25. Deficiencies were cited for failure to prevent accidents, substantiated with actual harm and past non-compliance. CI MS #29261 involved an anonymous report of a sick child brought to work with a staff member and was investigated with no deficiencies cited.
Findings
The facility was found not in compliance for CI MS #28771 with deficiencies cited for Failure to Prevent Accidents (F0689) at actual harm level, past non-compliance, corrected prior to survey entrance. No deficiencies were cited for CI MS #29261.
Deficiencies (1)
F0689 - The facility failed to ensure the safety of one resident during transport in the facility van when staff failed to secure the resident's wheelchair with appropriate safety belts, resulting in the resident sustaining a sternal fracture and head lacerations. The responsible staff member was terminated and corrective actions were implemented prior to the survey.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 18, 2024
Annual Inspection
Date: Nov 18, 2024
Visit Reason
On 11/18/24 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 10/17/24. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 11/13/24. No deficiencies were cited in this desk review.
Inspection Report — Oct 17, 2024
Routine
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, care, medication storage, food safety, and facility maintenance at Vaiden Community Living Center.
Findings
The facility was found deficient in maintaining a safe and clean environment, including unsafe and damaged resident equipment, failure to implement care plans, improper personal hygiene care, unsecured medication storage, and improper food labeling and storage.
Deficiencies (5)
F 0584: The facility failed to maintain a safe, clean, and homelike environment as evidenced by a dirty wheelchair and an overbed table and bed headboard in disrepair for two residents.
F 0656: The facility failed to develop and implement a complete care plan meeting all resident needs, as one resident's Activities of Daily Living care plan was not followed.
F 0677: The facility failed to provide personal hygiene care, evidenced by long facial hair, unkempt hair, and long nails with brown substance for one resident.
F 0761: The facility failed to ensure proper storage of treatment medications and disinfectant wipes, as a treatment cart was left unlocked and unattended in the hallway.
F 0812: The facility failed to ensure food items in the kitchen refrigerator, freezer, and dry storage room were dated and labeled as required.
Report Facts
Residents sampled: 20
Care plans reviewed: 22
Survey days: 3
BIMS score: 6
BIMS score: 12
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed disrepair of Resident #27's headboard and overbed table and maintenance reporting procedures |
| Maintenance Director | Maintenance Director | Confirmed unreported maintenance issues with Resident #27's headboard |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported night shift responsibility for cleaning wheelchairs |
| Director of Nurses | Director of Nurses | Confirmed wheelchair cleaning responsibilities and observed dirty wheelchair |
| Administrator | Administrator | Confirmed wheelchair cleaning policy and unsecured treatment cart |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Reported on Resident #6's hygiene status and bathing responsibilities |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Confirmed care plan requirements and deficiencies for Resident #6 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and reported unlocked treatment cart and broken lock |
| Dietary Manager | Dietary Manager | Reported on food labeling and storage deficiencies in kitchen |
| Dietary Staff | Dietary Staff | Confirmed improper food storage and labeling in dry storage room |
Inspection Report — Oct 17, 2024
Annual Inspection
Date: Oct 17, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with a complaint investigation (CI MS#26464) at the facility from 10/15/24 through 10/17/24.
Complaint Details
Complaint investigation CI MS#26464 was conducted concurrently and the facility was found in compliance for resident neglect and hydration.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in environment, care plan, activities of daily living, medication storage, and food storage. The facility was in compliance with the complaint investigation for resident neglect and hydration.
Deficiencies (5)
F0584 - Safe/clean/homelike environment. The facility failed to maintain a clean and safe environment, evidenced by a dirty wheelchair and an overbed table and bed headboard in disrepair for two residents.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement an Activities of Daily Living care plan for one resident, resulting in inadequate personal care.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide necessary personal hygiene services to one resident, evidenced by long facial hair, unkempt hair, and long nails with brown substance.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure proper storage of treatment medications and disinfectant wipes on an unlocked treatment cart in the residents' hallway.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to ensure food items in the kitchen refrigerator, freezer, and dry storage room were dated and labeled properly.
Report Facts
Deficiencies cited: 5
Inspection Report — Oct 15, 2024
Life Safety
Date: Oct 15, 2024
Visit Reason
Survey conducted on 10/15/24 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Aug 13, 2024
Complaint Investigation
Date: Aug 13, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 25876) at the facility on 08/13/24.
Complaint Details
Complaint number CI MS# 25876 was investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The surveyor determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid Services and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 7, 2023
Complaint Investigation
Date: Nov 7, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23120 and CI MS #23324) at the facility on 11/6/23 through 11/7/23. The SA investigated allegations of abuse, neglect, quality of care/treatment/not groomed adequately, quality of care/residents not turned timely, neglect/pressure sores, neglect/other with no deficiencies cited.
Complaint Details
Complaint Investigation CI MS #23120 and CI MS #23324 involved allegations of abuse, neglect, quality of care, and pressure sores. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited during this complaint investigation.
Report Facts
Complaint Investigations: 2
Inspection Report — Sep 5, 2023
Complaint Investigation
Date: Sep 5, 2023
Visit Reason
The State Agency conducted a complaint survey, MS #22549, investigating Quality of Care/Treatment related to the resident having body odor, Quality of Care/Treatment related to the resident not being groomed adequately, and Resident/Patient/Client Assessment related to resident not receiving care for a medical change in status.
Complaint Details
Complaint MS #22549 investigated Quality of Care/Treatment issues including body odor, grooming, and assessment for medical change; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Aug 8, 2023
Annual Inspection
Date: Aug 8, 2023
Visit Reason
On 08/08/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 06/15/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 07/21/23. No deficiencies were cited in this desk review.
Inspection Report — Jun 15, 2023
Routine
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, and infection control at Vaiden Community Living Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, failing to implement a fluid restriction care plan, and not following infection prevention protocols during medication administration via PEG tube. Several residents were affected by these deficiencies.
Deficiencies (4)
F 0584: The facility failed to clean a visibly soiled overbed light and window blind and replace a broken window blind for two of 58 residents reviewed.
F 0656: The facility failed to implement a fluid restriction care plan for one of 17 care plans reviewed. Resident #9's fluid restriction was not followed by staff.
F 0692: The facility failed to follow a resident's physician prescribed fluid restriction for one of three residents on fluid restriction. Staff provided fluids beyond the prescribed limit to Resident #9.
F 0880: The facility failed to maintain strict aseptic technique during medication administration via PEG tube for one of four observations. Equipment was placed on unclean surfaces and not properly cleaned or disposed.
Report Facts
Residents reviewed: 58
Care plans reviewed: 17
Medication administration observations: 4
Fluid restriction: 1000
Water observed in pitcher: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in infection control deficiency related to PEG tube medication administration |
| RN #1 | Registered Nurse | Involved in PEG tube medication administration and infection control observation |
| Director of Nursing | Director of Nursing | Interviewed regarding fluid restriction care plan and infection control findings |
| CNA #1 | Certified Nurse Assistant | Interviewed about fluid restriction care plan compliance for Resident #9 |
| CNA #2 | Certified Nurse Assistant | Interviewed about fluid restriction care plan compliance for Resident #9 |
| Housekeeping Supervisor | Interviewed regarding cleaning schedules and observations of soiled environment | |
| Maintenance Director | Interviewed regarding maintenance requests and observations of broken blinds | |
| Administrator | Interviewed regarding maintenance follow-up and environmental concerns |
Inspection Report — Jun 15, 2023
Annual Inspection
Date: Jun 15, 2023
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 6/13/23 through 6/15/23. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation related to F584, F656, F692 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements related to maintaining a safe and clean environment, implementing comprehensive care plans, maintaining nutrition and hydration status, and infection prevention and control practices.
Deficiencies (4)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to clean a visibly soiled overbed light and window blind and replace a broken window blind for two residents, and did not ensure timely maintenance and cleaning of blinds and light covers in multiple resident rooms.
F0656 - Develop/implement comprehensive care plan. The facility failed to implement a fluid restriction care plan for one resident on dialysis, resulting in staff providing fluids outside the prescribed limits.
F0692 - Nutrition/hydration status maintenance. The facility failed to follow a resident's physician-prescribed fluid restriction, allowing fluids to be present in the resident's room contrary to orders.
F0880 - Infection prevention and control. The facility failed to maintain strict aseptic technique during medication administration via PEG tube for one resident, including improper handling and storage of equipment and potential contamination risks.
Report Facts
Deficiencies cited: 4
Inspection Report — Jun 14, 2023
Life Safety
Date: Jun 14, 2023
Visit Reason
Survey conducted on 6/14/23 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Mar 30, 2023
Date: Mar 30, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction report for Vaiden Community Living Center, documenting the results of a regulatory survey completed on March 30, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report — Mar 30, 2023
Complaint Investigation
Date: Mar 30, 2023
Visit Reason
The State Agency conducted a complaint survey, MS #20992, from 3/29/23 to 3/30/23 regarding feeding assistance, pressure ulcers, misappropriation of property, repositioning and neglect.
Complaint Details
Complaint MS #20992 involved feeding assistance, pressure ulcers, misappropriation of property, repositioning and neglect; the complaint was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Mar 30, 2023
Routine
Date: Mar 30, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 3/29/23 through 3/30/23.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Feb 10, 2023
Complaint Investigation
Date: Feb 10, 2023
Visit Reason
The State Agency conducted a complaint survey, MS CI #20290 at the facility from 2/9/23 to 2/10/23.
Complaint Details
Complaint MS CI #20290 alleged accidents related to unwitnessed falls. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid. There were no citations written on MS CI #20290 for Accidents related to Unwitnessed Fall.
Report Facts
Complaint count: 1
Inspection Report — Jul 6, 2022
Complaint Investigation
Date: Jul 6, 2022
Visit Reason
The State Agency conducted a complaint survey MS #18650 and MS #18651 from 7/5/22-7/6/22.
Complaint Details
Complaint MS #18650 alleged Quality of Care/Medical Doctor orders not followed, Dehydration, Nutrition and complaint MS #18651 alleged Neglect, Pressure Sore and Medical Doctor orders not followed. Both complaints were not substantiated.
Findings
The surveyor determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 22, 2022
Annual Inspection
Date: Mar 22, 2022
Visit Reason
On 3/22/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 02/09/22. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that your facility be placed back in compliance effective 03/07/22. No deficiencies were cited in this desk review.
Inspection Report — Feb 10, 2022
Routine
Date: Feb 10, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Feb 10, 2022
Life Safety
Date: Feb 10, 2022
Visit Reason
Survey conducted on 02/10/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Feb 9, 2022
Routine
Date: Feb 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, PASARR screening, care planning, oxygen therapy, infection prevention and control, medication administration, and visitor screening at Vaiden Community Living Center.
Findings
The facility failed to notify a resident's representative of hospital transfer, did not complete required PASARR Level 2 screenings, failed to develop an oxygen care plan, and did not follow proper oxygen tubing protocols. Infection control deficiencies included failure to perform hand hygiene during meal and hydration passes, improper medication handling, and failure to screen a contract worker for COVID-19 symptoms.
Deficiencies (5)
F 0623: The facility failed to notify the resident representative in writing of a hospital transfer for one of 22 residents reviewed.
F 0645: The facility failed to accurately complete a PASARR Level 2 change in status form for one of three residents reviewed.
F 0656: The facility failed to develop an oxygen care plan for a resident with a physician's order for oxygen therapy.
F 0695: The facility failed to date oxygen tubing, provide storage bags, and place oxygen in use signage for two residents on oxygen therapy.
F 0880: The facility failed to prevent infection spread by not performing hand hygiene during meal and hydration passes, improper medication handling, and failure to screen a contract worker for COVID-19 symptoms.
Report Facts
Residents reviewed for transfer notification: 22
Residents reviewed for PASARR screening: 3
Residents reviewed for oxygen therapy care plan: 4
Residents reviewed for oxygen tubing and signage: 4
Residents affected by oxygen tubing deficiencies: 2
Days contract worker was not screened: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration infection control deficiency |
| CNA #1 | Certified Nurse Assistant | Named in hydration pass hand hygiene deficiency |
| NA #3 | Nursing Assistant | Named in meal tray pass hand hygiene deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen tubing and infection control deficiencies |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including transfer notification, PASARR screening, oxygen care plan, infection control, and visitor screening |
| Social Service Director | Social Service Director | Interviewed regarding transfer notification deficiency |
| Social Worker | Social Worker | Interviewed regarding PASARR screening deficiency |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding oxygen tubing and signage deficiencies |
| Contract X-ray Technician | Contract X-ray Technician | Named in visitor screening deficiency |
Inspection Report — Feb 9, 2022
Annual Inspection
Date: Feb 9, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 2/7/22 through 2/9/22. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations, with deficiencies cited in notification before transfer, PASARR screening, care planning, respiratory care, and infection prevention and control.
Deficiencies (5)
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to notify the resident representative in writing of a transfer to the hospital for one of 22 residents reviewed for transfer, Resident #46.
F0645 - PASARR Screening for MD & ID. The facility failed to accurately complete a PASRR Level 2 change in status form for one of three residents reviewed for PASRR, Resident #44.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop an oxygen care plan for a resident with a physician's order for oxygen therapy, Resident #4.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to date oxygen tubing, provide storage bags for oxygen tubing, and place oxygen in use signage on the entrance door for two residents, #4 and #247.
F0880 - Infection Prevention & Control. The facility failed to prevent the spread of infection by not performing hand hygiene while passing meal trays and ice, inappropriate handling of medication during medication pass, and failure to screen a vaccinated contract worker for COVID-19 signs and symptoms.
Report Facts
Deficiencies cited: 5
Inspection Report — Sep 8, 2021
Complaint Investigation
Date: Sep 8, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI) on 9/8/21 for CI MS#17959 regarding allegations of Quality of Care/Treatment.
Complaint Details
CI MS#17959 regarding allegations of Quality of Care/Treatment was unsubstantiated with no deficiencies cited.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with the regulations required by CMS.
Report Facts
Complaint count: 1
Inspection Report — Jun 1, 2021
Complaint Investigation
Date: Jun 1, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI), CI MS #17694 on 6/1/21.
Complaint Details
CI MS #17694: The complaint investigation for quality of care/treatment was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Centers for Medicare and Medicaid Services requirements for participation. No deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 24, 2021
Complaint Investigation
Date: Feb 24, 2021
Visit Reason
The State Agency conducted complaint investigation (CI) MS #17448 from 02/23/2021 through 02/24/2021.
Complaint Details
Complaint CI MS #17448 was investigated and not substantiated for quality of care.
Findings
The facility was found to be in compliance with the Minimum Standards for the Aged or Infirm. CI MS #17448 was not substantiated for quality of care.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 24, 2021
Routine
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation (CI) MS #17448 were conducted by the State Agency from 02/23/2021 through 02/24/2021.
Complaint Details
Complaint investigation CI MS #17448 was not substantiated for quality of care.
Findings
The facility was found to be in compliance with 42 CFR 483.30 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. The complaint investigation MS #17448 was not substantiated for quality of care.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 24, 2021
Routine
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) from 02/23/2021 through 02/24/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Sep 25, 2020
Complaint Investigation
Date: Sep 25, 2020
Visit Reason
The State Agency conducted a complaint survey, MS #16930 at the facility on 07/23/2020. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Complaint Details
Complaint MS #16930 was substantiated for Abuse and Neglect with deficiencies cited.
Findings
The SA substantiated the complaint for Abuse and Neglect and cited F0600 and F0609.
Deficiencies (2)
F0600 - The facility failed to ensure residents were free from abuse and neglect as substantiated by the complaint investigation.
F0609 - The facility failed to investigate and report allegations of abuse and neglect as required.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 10, 2020
Routine
Date: Aug 10, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period between 07/27/2020 and 08/09/2020 as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 22, 2020
Complaint Investigation
Date: Jul 22, 2020
Visit Reason
The State Agency conducted a complaint survey, MS #16930 at the facility on 07/23/2020. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid. The SA substantiated the complaint for Abuse and Neglect and cited F600 and F609.
Complaint Details
Complaint MS #16930 was substantiated for Abuse and Neglect. The allegation involved verbal abuse by a CNA towards Resident #1 and failure to timely report the incident. Deficiencies F600 and F609 were cited.
Findings
The facility was found not in compliance due to failure to ensure a resident was free from abuse and neglect and failure to report the allegation of abuse within the required timeframe.
Deficiencies (2)
F0600 - The facility failed to ensure Resident #1 was free from verbal abuse when a CNA used inappropriate language towards the resident and failed to report the incident timely. The CNA was terminated after the incident was reported.
F0609 - The facility failed to report an allegation of abuse involving Resident #1 within the required two-hour timeframe, delaying notification to administration and state officials.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 29, 2020
Routine
Date: Jun 29, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements under §483.80(g).
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network. The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 29, 2020
Routine
Date: Jun 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/29/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jun 22, 2020
Routine
Date: Jun 22, 2020
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 30, 2020
Complaint Investigation
Date: Apr 30, 2020
Visit Reason
A complaint investigation was conducted on April 30, 2020 in the facility.
Complaint Details
CI MS #16769: Complaint investigation regarding Facility Staffing and COVID-19 Infection Control was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated for Facility Staffing and COVID-19 Infection Control with no deficiencies cited. The facility was found in compliance with Federal and State requirements.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 12, 2019
Annual Inspection
Date: Jul 12, 2019
Visit Reason
The State Survey Agency (SA) conducted an annual recertification survey at the facility from 7/9/19 to 7/11/19. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to deficiencies in comprehensive care planning, nutrition and hydration status maintenance, psychotropic medication management, pest control, and fire alarm system maintenance.
Deficiencies (5)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement and develop a comprehensive care plan related to nutrition and psychotropic medications for one resident.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to implement the Registered Dietitian's recommendation for a dietary supplement consistent with the resident's assessed needs for one resident.
F0758 - Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure that an antipsychotic medication was gradually reduced upon recommendation by the Nurse Practitioner and without documented contraindication for the reduction for one resident.
F0925 - Maintains Effective Pest Control Program. The facility failed to provide an effective pest control program to prevent flies observed in the dining room, resident rooms, and kitchen for three days of survey.
K0341 - Fire Alarm System - Installation. The facility failed to maintain a complete manual fire alarm system as manual pull stations near the exit doors on the 100, 200, and 300 halls did not activate the fire alarm system.
Report Facts
Deficiencies cited: 5
5 CMS Surveys
CMS Survey — Jun 18, 2025
Jun 18, 2025
CMS Survey — Feb 9, 2022
Feb 9, 2022
CMS Survey — Jun 15, 2023
Jun 15, 2023
CMS Survey — Oct 17, 2024
Oct 17, 2024
CMS Survey — Mar 30, 2023
Mar 30, 2023
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