Vista Grande Villa

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 42 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings Include:On 02/18/2026 at 9:17 A.M., The ambient air thermometer in the walk-in cooler was observed with accumulated and encrusted moist black droplets resting upon the metallic surface. On 2/18/2026 at 9:26 A.M., The walk in cooler metal wire shelving units was observed soiled with accumulated and encrusted food residue. On 2/18/2026 at 10:01 A.M., The clean equipment storage rack found two shallow pans with encrusted food residue on the rim. Director of Dining Services (DODS) P removed the pans to be washed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to justify the increased dose of an antipsychotic medication for one (R9) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.for one resident (Resident #15) of one reviewed for abuse/misappropriation. Review of Resident 15s (R15) clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed R15 was admitted on [DATE] with diagnosis that included cardiac diagnosis, and anxiety. R#15 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review of R15's clinical record included a progress note made by formal facility Social Worker (SW) L dated 1/23/25 at 10:04 and revealed SW L and Biller K had discovered on 01/22/25 that R15's family member had been misappropriating funds from R15's checking and savings account. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse/misappropriation, and implement interventions to protect the resident, for one resident (#15) of one reviewed. Review of Resident 15s (R15) clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R15 was admitted on [DATE] with diagnosis that included cardiac diagnosis, and anxiety. R15 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review of R15's clinical record included a progress note made by formal facility Social Worker (SW) L dated 1/23/25 at 10:04 and revealed SW L and Biller K had discovered on 01/22/25 that R15's family member had been misappropriating funds from R15's checking and savings account. The note continued to reveal that Adult Protective Services (APS) and the Ombudsman had been notified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Level II screening for one (R9) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for two (R16, R58) of 12 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician's orders for daily weights for edema monitoring for one (R27) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmacy recommendations for one (R9) of 5 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement transmission-based precautions according to the Centers for Disease Control and Prevention (CDC) for one (R16) of two reviewed.

Inspectors wroteBased on interview and record review the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term CareOmbudsman for two (Resident 54 and 56) of two residents reviewed.

Inspectors wroteThis Citation Pertains to Intake #2622799Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from mental, verbal and physical abuse by staff, for one Resident #1, of three residents reviewed.

Inspectors wroteThis Citation Pertains to Intake #2624374Based on observation, interview and record review the facility failed to develop and implement a plan of care related to deep tissue injury for one resident (#2) of two reviewed for skin care plans. Review of the clinical record revealed Resident 2 (R2) was admitted to the facility on [DATE] for short term rehabilitation after a fall at home that resulted in a pelvic fracture. Review of R2's skin assessment dated [DATE] revealed R2 was admitted with a Deep Tissue Injury (DTI) on the sacrum that measured in length 0.6 centimeters, a width of 0.5 centimeters. R2 scored a 15 indicating she was at risk for skin breakdown on the Braden Scale dated 9/16/25. Review of the nursing admission progress note reflected R2 was alert and oriented x 4. R2's Minimum Data Set had not yet been completed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an anti-coagulant Care Plan for one (Resident #19) of 11 reviewed for Care Plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise, and update a comprehensive, individualized plan of care for two (Resident #15 and Resident #26) of 11 residents reviewed for care plans, had a care plan revised for changes in resident's needs, resulting in the potential for not receiving the care needed and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care to one (Resident #15) of two residents reviewed who were dependent of all activities of daily living (ADLs), resulting in this resident not receiving the care needed to maintain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to document rationale for as needed (PRN) psychotropic medication orders that extended beyond 14 days for one (Resident #19) of five reviewed for unnecessary medications, resulting in the potential for an unnecessary medication regimen and adverse side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper storage and labeling of medications in one of one medication rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/collaberation/documentation of Hospice services provided to two (Resident #15, Resident #26) of two residents reviewed for Hospice services, resulting in a lack of coordination of services and care provided. Findings Include: Resident #15 (R15) Medical record reflected R#15 was admitted to the facility on [DATE]. Diagnoses of Left sided weakness from a Stroke, Dysphagia from the Stroke, Vascular Dementia, and Alzheimer's Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R#15 had a Brief Interview of Mental Status (BIMS) of 03 (severe cognitively impaired) out of 15. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 34 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of expired medications in two of two medication carts reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 34 residents.

Inspectors wroteThis citation pertains to intake MI00140099. Based on interview and record review, the facility failed to 1) ensure that the abuse policy was in accordance with federal regulations for abuse reporting timeframes and 2) immediately report to the State Agency an allegation of sexual abuse for one (Resident #140) of five reviewed for abuse resulting in an allegation of sexual abuse that was not reported timely to the State Agency and the potential for further allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) timely for one (Resident #28) of 12 reviewed for Minimum Data Set (MDS), resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one (Resident #7) of 12 reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care conference meetings were provided for three (Resident #7, #11 and #28) of three reviewed for care conferences, resulting in the potential for residents and/or their representatives not being provided the opportunity to participate in care planning.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a pressure ulcer on admission, obtain physician wound treatment orders on admission, and to complete physician ordered wound treatments, once obtained, for one resident (#14) of two residents reviewed with pressure ulcers resulting in the potential of delayed healing of a resident's pressure ulcer. Finding Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to justify the use of PRN (as needed) psychotropic medication and provide a duration of use for psychotropic medications for one (Resident #28) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions.