Vista Knoll Specialized Care Facility

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident 3) of three residents who required total assistance with activities of daily living (ADL bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) was free from injury when: 1. There was no documented evidence of fall preventive measures verbalized by facility staff, 2. The at risk for fall care plan was not person centered, 3.admission Record for Resident 3 had an inaccurate diagnosis listed. As a result of this deficient practice, Resident 3 got out of bed unassisted, fell and sustained a nasal fracture and was sent out to the hospital.

Inspectors wroteBased on observation, interview and record review the facility failed to timely complete the Minimum Data Set (MDS-a federally mandated clinical assessment tool) for one of three residents (Resident 3), reviewed for Resident Assessment, as required by Federal regulation S483.20(f)(3). This failure had the potential for a delay in care planning of Resident 3's ongoing clinical problems.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide care timely to Resident 1 when Resident 1 was not changed due to incontinence for one of six residents reviewed. This failure had the potential to affect Resident 1's condition . On 6/8/26 at 10 A.M., an unannounced visit to the facility was conducted relative to a complaint related to quality of care On 6/8/26 a record review of Resident 1's record was conducted . [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure a call light was working or functioning for one of six residents observed for Physical Environment. As a result, Resident 1's needs was not provided timely. On 6/8/26 at 10 A.M., an unannounced visit to the facility was conducted relative to a complaint related to quality of care. On 6/8/26 a record review of Resident 1's record was conducted . [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to replace a damaged low air loss mattress (LAL-mattress used to protect a residents' skin) for one of 27 sampled residents (168). This failure had the potential for Resident 168 to lose sleep during the night and put his skin integrity at risk.

Inspectors wroteBased on observations, interviews, and record review the facility failed to repair two of 27 residents' (10 & 168) rooms with damaged ceiling and wall .This failure had the potential to affect Resident 10 & 168's overall mood and well-being.

Inspectors wroteThe facility failed to accurately complete the Minimum Data Set (MDS-a required resident assessment in a nursing facility) for one of 27 residents reviewed for MDS accuracy. (Resident 127) This failure had the potential for Resident 127 to receive inadequate care. According to the current admission Record, Resident 127 was admitted to the facility on [DATE], with a primary diagnosis of Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may include hallucinations - seeing or hearing things that aren't there or delusions - a strong fixed belief about things that are untrue). On 9/23/25 at 8:46 A.M. Resident 127 was observed walking in the hallway, and using his four wheel walker. In an interview, he was pleasant, denied pain and spoke clearly. He knew his name, the time and place of where he was, and his situation in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately care for a resident's suprapubic catheter (SPC-a surgically inserted tube into the bladder through an incision below the belly button) for one of three residents reviewed for catheter care. (Resident 91) This deficient practice had potential for urinary tract infections (bladder infection) and dislodgement of the SPC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's (MD) orders for tube feeding (TF- uses a flexible tube to deliver liquid food, water, and medicine directly into the stomach) for one of six Residents (Resident 107) reviewed with enteral (refers to any method of feeding that uses the stomach to deliver nutrition and calories) nutrition. As a result, Resident 107 did not receive the full enteral feeding as ordered by the MD with a potential risk for malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one resident reviewed for intravenous (IV- medications administered directly into a vein) antibiotic therapy was provided care according to professional standards when: 1. Resident 129's IV antibiotic was administered three hours late. 2. Resident 129's peripherally inserted central catheter (PICC- a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use) was not measured according to physician's orders. This failure could potentially delay healing, increase the risk of infection and delay the identification of catheter-related complications for Resident 129.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident 7) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 7's PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 7's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to past traumatic experiences).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving antipsychotic (medication for mood, behavior, or thinking) medications had an appropriate diagnosis and monitored for side effects (SE) as recommended by the pharmacist for two of five residents (Resident 127 and Resident 16) sampled .These deficient practices placed both residents (Resident 127 and Resident 16) at risk for inappropriate treatment with psychotropic medication and undetected adverse (serious life-threatening SE) drug reactions, which could lead to dizziness, fainting, falls, or other serious complications. 1. According to the current admission Record, Resident 127 was admitted to the facility on [DATE], with a primary diagnosis of Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave. [...]

Inspectors wroteBased on observations and interviews the facility failed to clean up trash around the kitchen dumpsters. This failure had the potential to cause rodent and other pest infestations, which in turn could affect infection control.

Inspectors wroteBased on interview and record review, the facility failed to obtain an ordered medication from its contracted pharmacy for one resident (1), who had comfort care (care given to people who are near the end of life) orders. As a result, Resident 1 did not receive the ordered medication to provide comfort prior to his passing (dying).

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided as scheduled for one of three sampled residents (Resident 1) reviewed for Activities of Daily Living (ADL). This failure had the potential to result in poor personal hygiene and decreased psycho-social well-being for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for one out of 24 sampled residents (87), five unsampled residents (1, 38, 96, 309, 312), and two confidential group residents. This deficient practice had the potential for residents to feel uncomfortable.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) was free from unnecessary psychotropic (is any medication that affects brain activities associated with mental processes and behavior.) medications as per the facility's policy & procedure. * The facility failed to attempt gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.) and no clinical contra-indication was documented. * In addition, the facility failed to implement any non-pharmacological interventions (interventions not involving a medication for mental illness). Resident 3 was receiving several psychotropic including Anti-psychotic (used to manage/treat symptoms of some mental health disorders); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical records of 14 residents (Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96) in rooms A through H were stored in a safe and secure manner when the residents' clinical records were stored on a rolling bookcase in the residential hallway. This deficient practice had the potential for Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, and 96's private health information to become lost, destroyed, or accessed by unauthorized persons.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 301) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 301's wound treatment, the resident's roommate (Resident 88) was brought back to the room by staff. This deficient practice had the potential for Resident 301's care and treatment to be observed by other persons, and for the resident to feel embarrassed and undignified.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide pharmaceutical services to two non-sampled residents (Residents 1 & 2) to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of the residents. * The facility failed to ensure there was a valid physician medication order for Resident 1's morphine (controlled medication used to treat moderate to severe pain) infusion via morphine pump implanted (a surgical procedure performed to permanently implant a pump that delivers morphine to the spinal fluid to treat chronic pain) on 8/3/22. [...]

Inspectors wroteBased on interview and record review, the Consultant Pharmacist (CP) failed to report irregularities in Resident 2's Dulera inhaler (a combination of mometasone furoate and formoterol fumarate, used to prevent and lessen asthma symptoms) to the attending physician, Director of nursing and/or medical director and the facility administrator. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure medications were stored as per the facility's P&P and outdated medications were not available for residents' use. * Multiple expired medications observed in Unit 1 and Unit 2. * The opened Tuberculin PPD 1 ml vial (purified protein derivative, a multi-dose injectable solution used in skin test to determine if a patient has tuberculosis) was not labeled with the open date and was stored in the refrigerator in Unit 2 locked medication room. These failures had the potential to result in unsafe administration of medications to the residents and posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at an appetizing and palatable temperature for two of 15 confidential group residents and during a meal test tray observation. This failure had the potential for residents not to enjoy their food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 2 sampled residents, Resident 81, received a selected lunch meal and a chosen lunch entree. This deficient practice had the potential to result in weight loss and further compromise the resident's medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in accordance with food safety standards, when: - Spoiled produce was stored among non-spoiled produce. - Dented cans were stored among non-dented cans and were in circulation to be used. These deficient practices had the potential for residents to be exposed to the risk of foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 3 residents (43, 98) with hearing loss received the necessary services. This failure had the potential to decrease the quality of life for these two residents and could have caused communication breakdown between the residents and the staff.

Inspectors wroteBased on interview and record review, the facility failed to follow required standards related to the cool down process (a method to decrease the temperature within a required timeframe) for a potentially hazardous food (foods that require time and/or temperature control to prevent bacterial growth). As a result, there was a potential for food borne illness for 99 of 105 residents.

Inspectors wrote3b. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Huntington's Disease (a progressive brain disorder that causes uncontrolled movements, emotional problems,and loss of thinking) and bipolar disorder (extreme mood swings which ranged from depression to mania). On 2/27/19 at 10:59 A.M., an observation was conducted of LN 2. LN 2 brought a pitcher of water from the medication cart to Resident 68's bedside table. LN 2 poured the water from the pitcher into a cup for the tube feeding and medication administration. LN 2 returned the pitcher of water to the medication cart and used the pitcher of water for other residents. On 2/28/19 at 9:48 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated LN 2 should not have taken the pitcher inside Resident 68's room to avoid contamination and transmission of germs to other residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident 30) was protected from exploitation and misappropriation of funds. This failure placed Resident 30 at further risk of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of misappropriation of funds to the state agency for one residents (30). This failure had the potential to have placed Resident 30 at further risk of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one resident (30). This failure placed Resident 30 and other residents at risk of abuse due to the facility's incomplete investigation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to maintain or improve one of one sampled resident (13) with limited ability to sit upright. This failure had the potential to result in decline of Resident 13's ability to sit upright.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (13) remained free of injury from an accident hazard when they failed to identify the vinyl covering of a geriatric chair were torn, stiff and hard. This failure placed Resident 13 at risk to develop skin tears.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided per the physician's orders for 1 of 3 residents (13) reviewed for oxygen therapy. In addition, a physician's order did not have an indication for use related to oxygen administration for 1 of 3 sampled residents (404). This failure had the potential for residents to experience low oxygen saturation (amount of oxygen in the blood) levels which could lead to shortness of breath and/or respiratory distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a hospice agency's prospective visit calendar was present in the clinical record for one of three hospice residents (54). As a result, there was a potential for delayed or uncoordinated care between the facility healthcare team and the hospice agency.