Splendido at Rancho Vistoso

Inspectors wroteBased on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure that staff knocked prior to entering the rooms of 4 residents (#11, #3, #13 and #29). The deficient practice could impact the resident's level of privacy and their psychosocial well-being.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that comprehensive care plans were updated, care plan conferences were conducted, and care plans were revised to reflect residents' current needs for 3 of 3 sampled residents (#11, #17, and #33). The deficient practice had the potential to result in residents and/or their representatives not participating in the development and review of the plan of care, not understanding the resident's current care needs and goals, and staff providing care that was not based on an accurate, current, and individualized care plan.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to provide services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 38. The deficient practice could result in resident not provided with advanced care activities to meet their needs. Findings Include:The Facility Assessment with completion date of February 7, 2026 revealed an average daily census range of 28-35 for long-term care and 2-7 for short stay. Staffing plan included one FT (full-time) Director of Nursing (DON), 1-3 Licensed nurses providing direct care, and other nursing personnel with administrative duties that would include the lead nurse, minimum data set (MDS), assistant director of nursing (ADON), and Medical Records. Per the assessment, there should be at least one RN per 24-hour period; [...]

Inspectors wroteBased on observations, clinical record reviews, staff interviews and facility documentation and policy review, the facility failed to ensure there were no expired items readily available for resident use; failed to ensure that that medications were not left at bedside during medication administration; and, failed to provide for safe and secure storage for medication for two residents (#29, #1). The deficient practice could result in placing residents at risk for medication errors, unauthorized access, and potential adverse health outcomes.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored, dated and labeled. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one sampled resident (#17). The deficient practice could result in residents not receiving proper care according to their preferences or in potential harm to residents' lives.

Inspectors wroteBased on clinical record review, staff interviews, and the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, the facility failed to ensure the resident's signature and date on the NOMNC form was legibly signed and dated for one of three sampled residents (#44). The deficient practice could result in inaccurate NOMNC forms.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to develop and implement a comprehensive care plan that addressed one resident's (resident #1) current psychotropic medication regimen, including individualized interventions and monitoring. The deficient practice could result in inadequate monitoring and interventions, placing the resident at risk for adverse medication outcomes. The universe was 38, and the sample size was 5.

Inspectors wroteBased on clinical record review, staff interviews, observations, and facility policies, the facility failed to ensure that X-ray treatment orders were faxed in a timely manner in accordance with professional standards of practice for one resident (#36) , and failed to implement resident-directed care consistent with physician orders related to a swallowing deficit and use of a straw when drinking from a cup for one resident ( #1). The deficient practice could result in the resident choking or aspirating fluids, pain or further injury. The universe was 38, and the sample size was 2. Findings Include: -Regarding Resident #36: Resident #36 was admitted on [DATE] and discharged to the hospital on May 6, 2026 with diagnosis including Parkinson's disease, difficulty walking, orthostatic hypotension, pain in left hip, unspecified lack of coordination and muscle weakness. [...]

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights for one Resident (#6) out of the four sampled residents to be free from physical abuse by another resident (#10). The deficient practice could result in other residents being abused.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that there were no expired over the counter medications, nutritional supplements and syringes readily available for resident use, the sample size is 38 residents. The deficient practice could result in an increased risk for side effects.

Inspectors wroteBased on observations, interviews and review of policies and procedures, the facility failed to ensure food storage and service were in accordance with professional standards regarding storing of food boxes and staff wearing a bonnet. The deficient practices could increase the risk for foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, observations, and policy review, the facility failed to ensure that medications were not left unattended on a bedside table for one of 44 sampled residents(#142). The deficient practice could result in medications not being administered as ordered or another resident/person consuming the medication.

Inspectors wroteBased on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. The deficient practice could result in increased risk of injury to the resident.

Inspectors wroteBased on observation, clinical record, staff interviews and facility policy, the facility failed to ensure that medications were administered as ordered by the physician for 1 resident (#21). This practice could result in decreased deep vein thrombosis prophylaxis.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that cleaning clothes were stored in accordance with professional standards and that a beard nets were worn by two staff member. The deficient practice could result in placing residents at risk for food-borne illnesses.