Colonial Vista Post-Acute & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review [(PASARR)-an assessment used to identify people referred to nursing facilities with serious mental illness (SMI), intellectual disabilities (ID), and related conditions were not inappropriately placed in nursing homes for long-term care] had the required Level II referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge (a process that allowed residents admission to a nursing facility from a hospital without undergoing the PASSAR screening when certain criteria were met) in the facility for more than 30 days for 4 of 7 residents (Resident 35, 64, 44 and 8) reviewed for PASARR. Additionally, the mental health diagnoses were not accurately documented on the PASARR Level I. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities for 6 of 6 residents (Resident 74, 14, 66, 57, 15, and 69) reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for 2 of 5 residents (Resident 6 and 15) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity, respect and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed for safe administration of medications for 2 of 3 residents (Residents 35 and 79), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment placed the residents at risk for medication errors, adverse medication interactions, and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were able to use personal possessions in their room, specifically a personal refrigerator, for 2 of 2 residents (Residents 74 and 69) reviewed for resident rights. This failed practice placed the residents at risk of feeling like their rights had been taken away and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring and indications for use was in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 1 of 5 residents (Resident 10) reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and adverse side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision during meals consistent with resident needs for 1 of 3 residents (Resident 15) reviewed for accidents and supervision. This failure placed Resident 15 at risk for choking and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was continent of bowel and bladder received services and assistance to maintain their continent status for 1 of 2 residents (Resident 19) reviewed for bowel and bladder function. Failure to identify the decline in bladder and bowel continence and assess/determine causative factors, left the resident at risk for continued decline, feelings of embarrassment, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Infection Prevention and Control Guidelines and standards of practices were followed; 1. During a facility COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) outbreak to mitigate the risk for transmission of COVID-19 on 1 of 3 halls (South Hall); 2. During a residents Peripherally Inserted Central Catheter [(PICC) a long thin tube inserted through a vein in an arm to the heart to administer fluids, medications, and blood draws] dressing change for 1 of 2 residents (Resident 79). [...]

Inspectors wroteBased on interview and record review, the facility failed to honor residents' right to refuse a room transfer when their payor source changed for 1 of 2 residents (Resident 1) reviewed for choices. This deficient practice placed residents at risk for feeling vulnerable, disheartened and powerless.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food holding temperatures for 1 of 2 meal preparations (lunch meal on 9/26/2024) reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired foods in 1 of 1 dry storage and 1 of 1 walk in refrigerator reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 3 residents (Residents 62 and 214) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of ongoing assessments and monitoring in accordance with professional standards of practice for 5 of 5 residents (Residents 7, 23, 25, 122 and 1) reviewed for quality of care. The failure to assess and monitor for impaired skin integrity, edema, (swelling caused by presence of excess fluid in the body tissues) and bowel management placed the residents at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accidents by not ensuring residents who smoked were assessed for safety and kept their smoking paraphernalia stored in a locked area not accessible to other residents for 3 of 3 residents (Residents 23, 30, and 164) reviewed for smoking. Additionally, the facility failed to store a portable oxygen tank in a safe manner for 1 of 3 oxygen storage rooms (oxygen storage room [ROOM NUMBER]). This failure placed all residents at risk for avoidable accidents, injuries, and the potential risk of fire.

Inspectors wroteBased on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) for 2 of 3 residents (Residents 1 and 10) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, or treat skin to prevent the development of facility-acquired pressure injuries (PIs) for 1 of 3 residents (Resident 1) reviewed for PIs. This failed practice placed residents at risk for worsening or new pressure injuries, pain, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral feedings [(EF) the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, were unable to safely swallow, or need nutritional supplementation] for 1 of 1 resident (Resident 214) reviewed for EF. This failed practice placed the resident at risk for receiving expired and/or inaccurate enteral nutrition, adverse consequences, and complications of tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 5 residents (Resident 34) reviewed for trauma informed care. The facility failed to identify triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding Resident 34's history of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented for hand hygiene/handling medications during medication administration for 1 of 5 staff (Staff M), and use of personal protective equipment when entering a contact precautions (safety measures used by healthcare workers to prevent the spread of infectious agents that can be transmitted through direct or indirect contact) room for 1 of 3 resident rooms (room [ROOM NUMBER]) reviewed for infection control. These failures placed residents, staff, and visitors at risk for exposure to cross contamination of infectious disease.

Inspectors wroteBased on observation and interview the facility failed to provide a safe and functional environment for residents, staff, and visitors related to the handicap push plate (a button that allows people with disabilities to access an area by the push of a button) being out of service on 1 of 2 doors (main entrance). This failure placed residents, staff, and visitors at risk for accidents and a disrupted environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure repairs were made to 3 of 10 resident rooms (Residents 13, 15, and 39 - [NAME] Hall) that had large gouges (indentation or groove made in a surface to cause holes or damage) with peeling paint to the wall in the back and to the side of the resident's head of their bed and damage to the floor. Additionally, there were no curtains on the windows and the vertical blinds had missing panels/slats for 5 of 9 resident rooms (Rooms 13, 15, 16, 17, and 18-West Hall). The doors and furniture were worn and scratched. These failures placed residents in a less than homelike environment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure standard infection prevention and control precautions were implemented for 1) Hand hygiene practices for 2 of 5 staff (Staff J and N) observed during meal tray delivery to residents, 2) Staff use of personal protective equipment (PPE) when entering/exiting a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) Transmission Based Precaution (TBP, safe guards put in place to help prevent the spread of disease) room for 4 of 5 staff (Staff R,O,P and Q) reviewed for infection control, and 3) Staff's N95 mask (a specific type of mask used to protect against certain diseases) fit [...]

Inspectors wroteBased on interview and record review the facility failed to 1) identify and monitor individualized targeted behaviors prior to administering a psychotropic medication (drugs that affect brain activities associated with mental processes and behavior), 2) monitor for adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition), and 3) ensure adequate indications of use for 1 of 5 residents (Resident 54), reviewed for unnecessary medications. These failures placed the resident at an increased risk of medical complications, unnecessary psychotropic medication side effects and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 medication storage rooms (East/West Hall) and 2 of 5 medication carts (East/West Medication Cart #2 and South Hall Medication Cart) was free from expired medications. This failed practice placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications.