College Vista Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed maintains acceptable parameters of nutritional status, to prevent unintended significant weight loss for Two of three sampled residents (Resident 28 and Resident 8) in accordance to the facility's policy and procedures titled Weight Management Policy and Nutritional Assessment. 1. For Resident 28 who lost 17.3 pounds (lbs.) with 16.29 (%) percent of body weight six months from 106.2 lbs. on10/3/2025 to 88.9 lbs. on 4/3/2026 the facility failed to: a. Reassess Resident 28's food preferences, according in which the resident reported her preferred food. b. Conduct an IDT Interdisciplinary Team- with the party responsible involved to determine the possible root cause of Resident 28's weight loss. c. Update the care plan interventions to address her continued weight loss. d. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food and consumption items were handled appropriately to prevent contamination and spread of foodborne and waterborne illnesses by failing to: 1. Ensure the internal component of the ice machine, reservoir pan, was cleaned every 30 days as indicated on the manufacturer's specifications. 2. Ensure Certified Nurse Assistant (CNA) 1 performed hand hygiene after assisting in setting up Resident 23's meal tray and then immediately assisting Resident 7. These deficient practices had the potential to result in foodborne/waterborne illnesses and for the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that specialized rehabilitative services were provided by qualified personal when the Director or Rehabilitation (DOR), who was a Certified Occupational Therapist Assistant (COTA), transcribed the Physical Therapist (PT) evaluation findings into the Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs) for two of two sample residents (Resident 5 and Resident 34). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 7). This de cient practice has a potential for Resident 7 not able to call for help when needed for comfort and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge notification was sent to the Office of the State Long-Term Care Ombudsman (a state employee that advocate for the residents) for one of three sample residents (Resident 45) in accordance with the facility's policy and procedure titled Transfer and Discharge. This deficient practice had the potential to result in the Ombudsman not being aware of Resident 45's discharge to the General Acute Care Hospital (GACH) on 1/2/2026

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three sample residents (Resident 5 and Resident 32)'s Minimal Data Set (MDS, a resident's assessment) accurately reflected the resident's status to indicate the residents' functional range of motion (ROM, full movement potential of a joint) limitations in accordance to the facility's policy and procedure (P&P) titled Resident Assessment - RAI. This deficient practice resulted in the inaccurate documentation of Resident 5 and Resident 32's functional ROM limitations on the MDS and had the potential to negatively affect Resident 5 and Resident 32's plan of care and delivery of necessary care and services related to the range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for two of three residents (Resident 8, and Resident 34) by failing to: Resident 8's care plan was not developed to address fluid limitation which can cause fluid overload and can cause edema (retention of fluid in the body tissues). For Resident 34, a person-centered care plan was not developed for the left ankle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). These failures had the potential to place Resident 8 at risk for fluid overload --and Resident 34 at risk for further joint mobility decline and contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three sample Residents (Resident 5 and Resident 34), with limited range of motion (ROM, full movement potential of a joint) received the appropriate treatment and services by failing to: 1. Ensure Resident 5 and Resident 34's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs) accurately reflected the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Treatment from on 5/8/2026 and 5/11/2026. 2. Ensure Resident 5 and Resident 34's Minimal Data Set (MDS, a resident assessment) accurately indicated the residents' functional ROM limitations. 3. Ensure that Resident 34 received the annual PT assessment in 2025. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent unnecessary use of psychotropic medications (medication that affects mood and behavior) in accordance with the physician's order, and the facility policy and procedure titled, Use of Psychotropic Medication(s) for one of three sampled residents (Resident 2) by not monitoring side effects of Respirone (prescribed medication for mood and behavior) 0.5 milligrams (mg - unit of measurement). This failure had the potential to result in the resident receiving unnecessary medication or not sufficient dosage of medication to treat the behavioral disorder, and the potential to experience side effects with delayed or no treatment and prolonged use of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document two of three residents (Resident 8 and Resident 4) in their electronic medical record by failing to ensure that: 1. Resident 4's indicated use of Lorazepam (a psychotropic medication [medications that affect brain chemistry, altering mood, thoughts, perceptions, and behaviors] used to treat anxiety disorder) was accurately documented in Medication Administration Record (MAR) on 5/4/2026. 2. Resident 8's accurate weight was documented on the Interdisciplinary team (IDT a team of facility staff responsible in care planning residents care) assessment. 3.the corrected amount of Dilaudid (medication used to relieve pain) medication for Resident 8 was documented on Resident 8's progress notes and pre/post dialysis assessment communication form. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and ensure that three of three sample residents (Resident 6, 20, and 12) understood the terms of the facility's arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to court) as indicated in the facility's policy and procedures titled Arbitration Agreement. This deficient practice had the result in Resident 6, 20, and 12 not being informed of their rights and choices about important aspects of the residents' health, safety, and welfare under the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident ' s needs for 4 of 4 sampled residents (Residents 192, 20, 5 & 21) by failing to: 1. For Resident 192 had no care plan to address interventions and goals while receiving Lovenox (a medication or an anticoagulant or blood thinner that makes blood less likely to clot and can cause bleeding). 2. For Resident 20 the plan of care was not implement care Plan interventions who had a diagnosis of impaired immunity related to viral infection to monitor and document sign and symptom of delirium as indicated in care plan. 3. For Resident 5, there were no care plans indicating the specific activities needed since Resident 5 had impaired vision. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store and discard expired medication, and store Lorazepam safely for two of three sampled residents (Resident 31 and 36) controlled drugs (medications that can create mental and physical addiction or dependency) in a separately locked compartment in the medication storage room in accordance with the facility ' s policy and procedure (P&P), titled Medication Storage by failing to : 1. Properly store and discard a box of expired Microdot glucose gel (a medication used to treat low blood sugar) in the medication storage room. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 33 & 34) were treated with respect and dignity by ensuring residents body was covered while asleep in bed. This deficient practice resulted in Resident 33 and Resident 34 ' s unknown and/or unwanted exposure of the body and had the potential to lead to psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident tool) entries were accurate and reflect resident ' s status of one of three sampled residents (Resident 39) who was discharged home with home health services. The MDS was incorrectly coded as a transfer to a hospital which does not reflect the actual discharge disposition of the resident who was discharged home. This failure resulted in inaccurate documentation in the resident ' s medical record could impact continuity of care, facility reporting accuracy, and regulatory compliance. Incorrect discharge coding may also affect quality measures, reimbursement, and tracking of resident outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate monitoring of potential side effects for Lovenox (an anticoagulant or an injectable medication that thins blood or prevents development of blood clots) is documented for one of 3 sampled residents (Resident 192). This deficient practice had the potential for Resident 192 to develop adverse effect (undesired effect) and the staff not to notice sign and symptoms of bleeding and cause severe bruising and bleeding that is undetected and lead severe blood loss and eventually death.

Inspectors wroteBased on observation and interview, the facility staff failed to ensure one of three sampled residents (Resident 192), who was on a anticoagulants (blood thinners which makes blood flow through veins and arteries more easily, which means blood is less likely to clot), was free of any significant medication errors. This deficient practice had the potential to result in an increased or delayed effectiveness of the medication due to the incorrect route of the medication administered, and could potentially lead to further health complications.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the kitchen was in safe and sanitary condition by failing to: 1. Ensure the kitchen sink area did not have white residue (a small amount of something that remains after the main part has gone or been taken or used) on the drainage pipes and on the floor. 2. Ensure the kitchen floor did not contain white paint remnants (a small remaining quantity of something) 3. Ensure the kitchen drywall was not exposed. These deficient practices had the potential for foods to be contaminated and placed residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to explain an Arbitration Agreement (a provide agreement that allows individual parties to resolve disputes rather than in a lawsuit) to two of three sampled residents (Residents 18 and 29) correctly and thoroughly in a manner that the residents and/or their responsible parties could understand. Residents 18 and 29 reported the facility staff did not explain in a manner that they understand what an Arbitration Agreement and Arbitration Agreement to allow them to make an informed decisions and choices about important the aspects of their health, safety, and welfare. This failure resulted in Residents 18 and 29 ' volitation of resident ' s rights and not make an informed decision about their care to ensure they receive care according to their rights and preferences.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of two sampled residents who was at high risk for falls. The deficient practice had the potential to result in recurring falls for Resident 1 who sustained a fall on 3/27/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) who filed a grievance was provided with written grievance decision that included all the required information, in accordance with the facility ' s policy and procedure titled Resident and Family Grievances. This deficient practice violated in Resident 1 ' s right to receive a proper grievance report.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and interventions to prevent pressure injury ([PI]-damage to an area of the skin caused by constant pressure on the area for a long time) for one (1) of three (2) sampled residents (Resident 1) by failing to turn, reposition and off-offload (release pressure) from an area of the body every two hours while in bed, keep clean and dry after a bowel movement or wetness from urine due to incontinence (unwanted passage of urine or stool that you can't control). These deficient practices resulted in Resident 1 developing a facility-acquired Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on the intergluteal cleft (crease located between the two buttocks) area on 2/16/25. Resident 1 was discharged to home with home health services on 2/19/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and provide necessary wound care according to the physician's order for one of three sampled resident (Resident 1) by failing to ensure: 1. The Treatment Nurse (TXN) failed to assess Resident 1's surgical incision at the right hip with staples (a medical tool used to close wounds by joining the edges of skin together that are often used for deep wounds) and did not provide wound care to Resident's right hip as ordered by the physician's order since 8/14/24. 2. Assess and provide wound care on the left shin and perineal area due to MASD (moisture related skin damage) for Resident 1 on 8/1/24, 8/4/24, 8/18/24 and 8/19/24 (total 4 days). 3. The TXN conducted a thorough assessment and document weekly the skin condition for Resident 1 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals by failing to contact and document referrals to local contact agencies or other appropriate entities for one of two sampled residents (Resident 1) to ensure the resident received Home Healthcare services (medically necessary, skilled services provided at home prescribed by a physician for the treatment of an illness, injury, or medical condition) and Lovenox injection (medication to prevent blood clot formation administered under the skin with the use of a needle) as ordered by the physician. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from accident smoking hazards by failing to: 1. Supervise and monitor Resident 1, who was non-compliant with the facility's smoking policy, titled Resident Smoking, when the resident went to the facility's outdoor patio to smoke a cigarette while on oxygen. 2. Implement Resident 1's care plan interventions of being non-compliant with the facility's smoking schedule and policy that indicates facility staff would supervise Resident 1 while smoking. 3. Ensure the facility nursing staff maintained Resident 1's smoking materials, in accordance with the facility's policy and procedures (P&P) titled, Resident Smoking. 4. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident ' s will, or the will of the resident representative), when licensed vocational nurse (LVN) 3 pushed a long table to block the facility door leading to the patio, preventing Resident 3 from going to the outdoor patio. This deficient practice restricted Resident 1 ' s movement in the facility and resulted in Resident 1 verbalizing feelings of being upset.

Inspectors wroteBased on interview and record review, the facility failed to develop a smoking policy that identified procedures to implement and ensure the safety of one of 32 residents (Resident 1) who was noncompliant with the facility ' s smoking policy and procedure. Resident 1 who was receiving continuous oxygen therapy always kept a cigarette and lighter in his possession. On 7/31/24 Resident 1 was left unsupervised smoking in the patio when he lit up a cigarette in his mouth while an oxygen delivered via cannula (medical device to provide supplemental oxygen through the nares) tubing delivering oxygen (colorless and odorless gas needed for plant and animal life). [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure (P&P) to inform Resident 1 ' s responsible party when there was a change in condition requiring notification. Resident 1 responsible party was informed about Resident 1 ' s change of condition almost seven hours after the resident ' s COC and after Resident 1 was transferred to the general acute care hospital. This deficient practice violated the resident and/or the resident ' s responsible party ' s rights to be informed in advance about the resident ' s treatment and choose a possible treatment alternative or options and had the potential to negatively affect Resident 1 ' s physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) was immediately provided CPR (cardiopulmonary resuscitation a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse] consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) prior to the arrival of emergency medical personnel in accordance with the standard of practice and the facility's policy and procedure titled Medical Emergency Response and Cardiopulmonary Resuscitation (CPR) by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia (condition in which tissues of the body are starved of oxygen), pneumonia (lung inflammation) and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and who was receiving continuous oxygen therapy by failing to: 1. Monitor and conduct respiratory assessment for complications associated with the use of oxygen and notify the primary physician (Physician 1). On [DATE] at 5:30 AM, Resident 41 verbalized not feeling well and asked the Licensed Vocational Nurse (LVN) 1 for her oxygen tank to be replaced because the resident, felt it was empty. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of need for four of four sampled residents (Resident 17, 29, 31, and 34) by failing to ensure the resident's call light was within reach as indicated in the facility's policy and procedure and resident's care plan. This deficient practice had the potential for Resident 17, 29, 31, and 34) not to receive or received delayed care to meet necessary care and services that could result in fall and accident.

Inspectors wroteBased on interview and record review, the facility failed to ensure five out of five employees had the specific competency and skill sets necessary to provide cardiopulmonary resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse] consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) for Resident 41. This deficient practice resulted in the delay in the initiation of CPR and life saving measures for Resident 41 and placed residents at risk for not receiving appropriate services, treatments and unsafe level and type of identified care necessary for the resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their enhanced standard precaution (a resident-centered and activity-based approach for preventing multi-drug resistant organism [MDRO Bacteria that resist treatment with more than one antibiotic] transmission in skilled nursing facilities (SNF) for one of five sampled residents (Resident 20) when staff was observed providing care to Resident 20 without wearing the proper personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). This failure placed Resident 20 at risk for exposure to infectious organisms increasing the risk of infections and a spread of infection to other residents and the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 92) was treated in a dignified and respectful manner as demonstrated by failing to provide appropriate body coverage when Certified Nursing Assistant (CNA) 7 transported Resident 92 in the hallway to the shower room. This deficient practice had the potential to cause Resident 92 to be embarrassed and result in psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 22) had the correct setting for a low air loss mattress (a mattress filled with air that used for the prevention of pressure ulcers) for the prevention of pressure ulcers (wound caused when an area of skin is placed under pressure). This failure placed Resident 22 at risk of developing pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed ensure the attending physician acted upon and document in the residents' clinical records the rationale to the consultant pharmacist recommendation during the drug regimen to re evaluate use of psychotropic medication Seroquel (medications that affects mood and behavior) to consider whether or not the medication be reduced or discontinued for one of five sampled residents (Resident 37) and consider GDR (Gradual Dose Reduction- decreasing the dosage of medication slowly) with eventual discontinuation if appropriate and document rationale for necessity to continue therapy. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the route of medication administration matched the label on the bubble pack (a type or medication tablets packaging), the physician ' s orders and Medication Administration Record (MAR) for Bromocriptine Mesylate (medication used to treat Parkinson ' s Disease [a disorder of the nervous system that affects movement, including tremors) and Divalproex Sodium (medication used to treat seizures and bipolar disorder [disorder associated with episodes of mood swings ranging from depressive lows to manic highs) for one of one sampled resident (Resident 17). This deficient practice had the potential to result in Resident 17 to receive medications in error or through the wrong route that could lead to choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided with timely respiratory care to ensure a clear airway by failing to suction and assess Resident 1 with respiratory distress before and after giving interventions, in accordance with the resident ' s plan of care. This failure had a potential to result in Resident 1 ' s aspirations, complications including death.

Inspectors wroteBased on interviews and record review, the facility staff failed to respect the resident and resident ' s representative ' s rights for visitation privacy during and at end of life for one of three sampled residents (Resident 1) who was under the care of hospice services and expired on [DATE] at around 9:20 PM. This deficient practice violated Resident 1 ' s rights for personal privacy and confidentiality, including dignity and respect when Resident 1 ' s body was left exposed by the facility hallway, on [DATE] while facility staff look for a private room to transfer the resident ' s body.