Azria Health Rose Vista

Inspectors wroteBased on observation, provider interview, staff interviews, record review and policy review, the facility failed to provide timely and adequate skin care to prevent worsening of pressure ulcers for 2 of 3 residents reviewed. Resident #6 developed a pressure injury on her heel and staff failed to call the doctor when there was a change in the wound. Resident #71 was admitted to the facility with an identified Moisture Associated Skin (MASD), and staff failed to get a doctor's order for treatments. The facility reported a census of 69 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. [...]

Inspectors wroteBased on facility document review, staff interviews and clinical record review the facility failed to establish and implement a restorative nursing program to help prevent residents from decline for residents discharged from Physical Therapy/Occupational Therapy (PT/OT) services. The facility reported a census of 69 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, document review, resident interview, staff interview and policy review, the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #8, #12, #20 and #38). The facility reported a census of 69 residents.

Inspectors wroteBased on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 4 of 4 residents with a pureed diet (Resident #6, #13, #26, and #52) reviewed and also all the residents that ate the lunch meal on 11/19/25. The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, document review, and staff interviews the facility failed to notify the resident's representative / family / Power of Attorney (POA) and the resident's primary care physician of a stage 2 pressure ulcer for 1 of 3 residents (Residents #1) reviewed. The facility reported a census of 69 residents.

Inspectors wroteBased on observation, family interview, staff interviews, clinical record review and policy review, the facility failed to implement the established interventions to prevent falls for 2 of 3 residents reviewed. Residents #39 and #1 had frequent falls and interventions included gripper strips on the floor to prevent slipping. Observations revealed that the staff failed to apply the safety strips. The facility reported a census of 69 residents.

Inspectors wroteBased on staff interview, Electronic Health Records (EHR), document review, staff interview and policy review the facility failed to maintain medical records on a resident that were complete and accurate by failing to document a pressure ulcer in the EHR appropriately for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to properly use universal infection control measures (hand hygiene and proper glove use) while completing peri cares and catheter cares for 1 of 3 residents (Resident #32) reviewed. The facility further failed to properly wear personal protective equipment (PPE) while completing personal cares for a resident with Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #1). The facility reported a census of 69 residents.

Inspectors wroteBased on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portion of fried rice for 13 of 15 residents who received carbohydrate controlled or consistent carbohydrate diets. The facility reported a census of 49 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food. The facility reported a census of 49 residents.

Inspectors wroteBased on observations, clinical record review, staff interview and resident interview, the facility failed to follow physician's positioning orders for 1 of 1 resident's (#16) reviewed. The facility reported a census of 49 residents. Findings Include: On 11/04/24 at 10:51 AM, Resident #16 was observed lying supine (flat on the back) in bed. A sign was observed at the head of her bed that directed staff to keep the head of her bed elevated above a 30-degree angle at all times. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, Non-Alzheimer's dementia, dysphagia (difficulty swallowing), Gastro-Esophageal Reflux Disease (GERD), and Calculus of Gallbladder (gallstones). [...]

Inspectors wroteBased on observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter and peri-care to prevent the development of communicable disease and infection for 2 of 2 residents (#16 & #27) reviewed. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, family interview, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not completing an x-ray ordered by a physician in a timely manner for 1 of 3 (Resident #1) residents reviewed. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, staff interview, family interview and policy review the facility failed to notify the Power of Attorney (POA) with resident medication changes for 1 of 3 residents (Residents #4) reviewed. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to obtain consent from the Power of Attorney (POA) to start a psychotropic medication for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 48 residents.

Inspectors wroteBased on observations, policy review, resident interview, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care for 2 of 3 residents reviewed (Resident #2 and #4). The facility reported a census of 48 residents.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to treat residents with dignity while providing assistance with meals. The facility reported a census of 49 residents.

Inspectors wroteBased on personnel file review, facility record review, facility policy review, and staff interview the facility failed to complete a back-ground check for a new employee, prior to employment, for 1 of 5 staff reviewed. The facility reported a census of 49 residents. Findings Include: Facility New Employee Data form documented the facility hired Staff D, Registered Nurse on 4/28/23. Single Contact License & Background Check for Staff D, documented completion on 5/1/23 at 8:17 AM. Facility payroll record for Staff D, revealed Staff D worked 4/29/23 at 1:45 PM - 6:30 PM and 4/30/23 at 11:45 AM - 6:30 PM. Facility policy Background Check Investigations, revised 3/2019, documented background and criminal checks are initiated with offer of employment or contract agreement, and completed prior to employment. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of three residents reviewed (Resident #20). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide a comprehensive care plan related to edema for a resident with an order for a diuretic with a diagnosis of localized edema for 1 of 1 residents reviewed (Resident #47). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to follow a physician order for 1 of 8 residents reviewed (Resident #44). The resident was found to have audible wheezes in her breathing and the doctor prescribed a steroid medication. The order did not get entered into the electronic chart or get administered. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, observation, and staff interview the facility failed to ensure that residents were offered nutritional supplements when meal consumption had decreased for Resident #1. The resident had a decline in health that included significant weight loss and the dietician recommended a supplement as needed. The supplement was not used. The facility reported a census of 49 residents.