Vista Grande Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.

Inspectors wroteBased on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist's recommendations in a timely manner for three (#2, #3 and #4) of five residents out of 36 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #2, Resident #3 and Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure nursing staff disinfected blood pressure cuffs and sit-to-stand mechanical lifts in between residents;-Ensure nursing staff performed appropriate hand hygiene in between assisting residents; and, -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#2) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to protect Resident #2 from sexual abuse by Resident #73 on 12/11/25.

Inspectors wroteBased on record review and interviews, the facility failed to report allegations of abuse in accordance with state law for two of two allegations of abuse. Specifically, the facility failed to: -Report an allegation of sexual abuse by Resident #73 towards Resident #2 on 12/11/25 to the ombudsman; and, -Report an allegation of sexual abuse by Resident #18 towards Resident #48 on 5/15/26 to the State Agency and the ombudsman.

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of sexual abuse for one (#48) of two residents of 36 sample residents. Specifically, the facility failed to investigate an allegation of sexual comments made by Resident #18 towards Resident #48 on 5/15/26.

Inspectors wroteBased on record review and interviews, the facility failed to provide a rationale to act upon a third party guarantee of payment to the facility for one (#3) of one resident out of 36 sample residents. Specifically, the facility failed to ensure they did not violate federal guidelines for placing a [NAME] on Resident #3's property for $28,000.

Inspectors wroteBased on observations, record review and interviews, the facility failed to to ensure residents received treatment and care in accordance with professional standards of practice for one (#7) of six residents out of 36 sample residents. Specifically, the facility failed to ensure a registered nurse (RN) completed a head-to-toe assessment after a fall resulting in a hip fracture for Resident #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care for one (#7) resident reviewed for hearing problems out of 36 sample residents. Specifically, the facility failed to consistently ensure Resident #7`s hearing aids were working and placed in the resident's ears.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment to attain the highest practicable mental and psychosocial well being for two (#2 and #18) of two residents out of 36 sample residents. Specifically, the facility failed to: -Consistently monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs for Resident #2; and, -Identify and implement effective interventions for Resident #18's sexual behaviors.

Inspectors wroteBased on record review and interviews, the facility failed to meet all the requirements for the provisions of hospice care for two (#67 and #41) of two residents reviewed for hospice care services out of 36 sample residents. Specifically, the facility failed to: -Ensure hospice notes were readily available in Resident #67 and Resident #41's electronic medical records (EMR); -Ensure Resident #67 and Resident #41's comprehensive care plans were developed with a delineation of care responsibilities between the facility staff and the hospice care services team; and, -Ensure there was a designated hospice care services coordinator for the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#1) of three residents reviewed for pressure injuries out of five sample residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure injury for Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on [DATE] with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls.

Inspectors wroteBased on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#1) of two residents out of three sample residents. Specifically, the facility failed to timely report an injury of unknown origin for Resident #1 to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation of abuse and neglect for one (#1) of one resident out of three sample residents. Specifically, the facility failed to complete a thorough investigation when Resident #1 sustained an injury of unknown origin.

Inspectors wroteIII. Resident #58 A. Resident status Resident #58, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included cerebral infarction (stroke), hemiplegia (paralysis to one side of the body), and Alzheimer's disease. According to the 4/11/24 MDS assessment, Resident #58 had significant cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #58 required significant assistance with transferring, toileting, walking and incontinence care. The resident was dependent on staff for lower body dressing. B. Record review A review of the comprehensive care plan, dated 5/7/24 (during the survey), documented the resident was at risk to fall. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure each residents had the right to formulate an advance directive for three (#36, #37 and #57) of five residents reviewed for advance directives out of 41 sample residents. Specifically, the facility failed to: -Provide written advance directive forms or discussions to Resident #36, #37 and #57; -Re-evaluate Resident #36, #37 and #57 for their decision-making capacity periodically; and -Re-evaluate Resident #36, #37 and #57 periodically to determine if their advance directives were still in line with their wishes.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure Resident #22, #24, #16, #29, #47, #53 and #58 were tested for COVID-19 when presenting signs and symptoms of an upper respiratory infection; and, -Ensure Resident #58, #164 and #165 received the COVID-19 vaccination after consenting for it. -Ensure the facility used preventative measures to help reduce the potential risk of COVID-19.

Inspectors wroteBased on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for five out of five staff reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #2, #4, #5 and #6 and certified nurse aide with medication authority (CNA-Med) #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#1, #23 and #38) of nine residents reviewed for dignity out of 41 sample residents. Specifically, the facility failed to: -Ensure staff treated Resident #1 with respect and dignity by acknowledging and responding to the resident when she spoke to them; -Ensure Resident #23 was treated with respect and dignity during meals; and, -Ensure Resident #38 was not yelled at or moved hastily when he got stuck on another resident' s chair in the dining room.

Inspectors wroteBased on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#15 and #20) of five residents reviewed for unnecessary medications out of 41 sample residents. Specifically, the facility failed to ensure informed consents, which included the risks associated with taking a psychotropic medication, were obtained for Resident #15 and Resident #20.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that personal funds accounts were managed adequately for four (#1, #2, #7 and #28) of five residents reviewed for personal funds accounts out of 41 sample residents. Specifically, the facility failed to: -Have signed written authorizations to manage the personal funds accounts for Resident #7; and, -Have personal funds withdrawal sheets signed to ensure the residents' permission was obtained to withdraw funds from their personal needs accounts for Residents #1, #2, #7 and #28.

Inspectors wroteBased on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#2 and #7) of five residents reviewed for personal funds accounts out of 41 sample residents. Specifically, the facility failed to notify Resident #2 and Resident #7, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#1 and #20) of three residents reviewed for abuse were free from abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #1 was free from potential sexual abuse by Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#1 and #27) of three residents out of 41 sample residents. Specifically, the facility failed to ensure: -Resident #1 was evaluated for the use of a restraint; -Consent was signed for the use of a restraint for Resident #1; -Obtain a physician's order for the use of a restraint for Resident #1; -Quarterly safety risk assessments were completed for the use of restraints for Resident #1; -Less restrictive measures attempted and proven unsuccessful for Resident #1 and Resident #27 were documented; -Risks versus benefits of restraint use were completed by the physician for Resident #1 and Resident #27; and, -Trial periods without the restraints were attempted for Resident #1 and Resident #27 to determine if the restraints were still necessary.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#57 and #36) of six residents with limited range of motion received appropriate treatment and services out of 41 sample residents. Specifically, the facility failed to: -Provide restorative therapy services to Resident #57 and Resident #36; and, -Provide ordered occupational therapy services to Resident #36.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#3) of one resident reviewed for supplemental oxygen use out of 41 sample residents. Specifically, the facility failed to: -Administer oxygen in accordance with the physician's order for Resident #3; -Ensure the staff reminded and encouraged Resident #3 to wear his oxygen; and -Ensure clear communication when Resident #3 should use his oxygen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in two of three medication storage carts and one of one medication rooms. Specifically, the facility failed to: -Ensure all refrigerated medications and biologicals were stored at the appropriate temperature; and, -Ensure medications were not expired.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective fall prevention interventions for one (#51) of seven residents reviewed for falls of 30 sample residents. Specifically, the facility failed to: -Accurately assess Resident #51 for fall risk after a fall outside of the facility; -Implement immediate actions to prevent further falls/incidents after Resident #51 reported a fall; -Reassess Resident #51's risk for falls after the resident reported a possible fall; -Conduct a timely investigation after Resident #51 reported a fall; -Ensure Resident #51's call light was within reach; and -Ensure adequate supervision to prevent unsafe resident self-transfers. Record review showed the resident was evaluated for increasing weakness concerns by nursing staff, and a risk for falls after a fall outside of the facility. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the facility assessment was conducted to determine resources necessary to care for its resident population competently during both day-to-day operations and emergencies. Specifically, the facility failed to ensure the facility assessment was accurate and comprehensive to include the following: -An accurate number of residents who utilized non-oral communication; -Contracts, memoranda of understanding ([NAME]), or other agreements for services needed for regular operations and emergencies for hearing and language interpretation; and -Staff competencies necessary to provide the type of care needed for residents who used non-oral communication. Cross-reference with F558, reasonable accommodation of needs and preferences.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of one medication storage refrigerator. Specifically, the facility failed to ensure vaccines and Tuberculin purified protein derivative (PPD) were stored according to practice standards and manufacturer guidelines.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide accommodation of needs for one (#13) of two residents reviewed for language and communication needs of 30 sample residents. Specifically, the facility failed to provide consistent use of a sign language interpreter to promote communication. Cross-reference F838, facility assessment of resident needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure proper pneumococcal immunizations for two (#34 and #24) of five residents reviewed out of 30 sample residents. Specifically, the facility failed to ensure Residents #24 and #34 received pneumococcal vaccines per the Centers for Disease Control and Prevention (CDC) guidelines.