Vista Manor Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate, communicate, and document the change in diabetic treatment plan for a chronically ill resident who required a surrogate for decision making, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. Resident #1 and her representative were not informed of the risks associated with not receiving diabetic care and were not given the choice to make an informed decision on the treatment plan. The failure in care coordination resulted in lack of diabetes care and monitoring according to resident/family wishes for 48 days, during which the resident developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's Interdisciplinary Team (IDT) failed to protect the resident's right to be free from neglect by failing to identify the need for a diabetic treatment plan for a type II diabetic resident with a history of uncontrolled diabetes, chronic kidney disease, and recurrent urinary tract infections which placed her at a high risk for decline, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. This failure resulted in a lack of proper blood glucose monitoring and treatment for 48 days, during which resident #1 developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate and communicate effectively among the interdisciplinary team to ensure diabetic residents received continuity of care in accordance with professional standards of practice, the care plan, and resident choice to attain or maintain their highest practicable physical, mental and psychosocial wellbeing, (#1). This failure in care coordination resulted in a lack of proper blood glucose monitoring and treatment for 48 days, during which resident #1 developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. The resident required emergency 911 transfer to the hospital and admission to the Intensive Care Unit (ICU), for 3 days. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified and addressed a systemic process failure related to coordination, communication, and continuity of care for a resident requiring diabetes management. Following a resident's hospitalization for complications related to not receiving diabetic treatments for 48 days, the facility failed to immediately identify the factors that contributed to the resident's decline. Approximately three months later, after the survey team identified the incident, the QAPI committee initiated a Performance Improvement Plan (PIP) that lacked documentation and root cause. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable fall with fracture for 1 of 3 residents reviewed for falls, of a total sample of 8 residents, (#1).

Inspectors wroteBased on observation and interview, the facility failed to promote a dignified existence related to standing over a resident while assisting with eating for 1 of 1 resident reviewed for dignity, out of a total sample of 40 residents, (#9).

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of Level I Preadmission Screening and Resident Review (PASRR) findings with the resident assessment process to identify, communicate, and incorporate a diagnosis of Post-Traumatic Stress Disorder (PTSD) into the resident's assessment documentation for 1 of 1 resident reviewed for PASRR, resident #4, from a total sample of 40 residents. Review of resident #4's medical record revealed the initial PASRR dated 11/24, did not identify a diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of resident #4's record further revealed an updated PASRR completed on 4/07/2026, documented as PASRR UPDATED.pdf, which identified a diagnosis of PTSD and required update to the resident's assessment documentation. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or revise a comprehensive, person-centered care plan to address a diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 1 resident reviewed for care planning of a total sample of 40 residents, (#4). Resident #4 was admitted to the facility on [DATE] from an acute care hospital. A psychiatric evaluation dated 2/20/25 identified PTSD as part of the resident's mental health diagnoses. Behavioral health progress notes dated 3/28/25, 7/14/25, 7/31/25, 8/21/25, 9/17/25, 9/23/25, 10/1/25, 10/14/25, and 10/28/25 documented a diagnosis of Post-Traumatic Stress Disorder (PTSD). A comprehensive Minimum Data Set (MDS) assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE] identified PTSD in Section I (Active Diagnoses). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order was obtained prior to the administration of oxygen therapy for 1 of 1 resident reviewed for oxygen (O2) therapy out of a total sample of 40 residents, (#89).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure waste was properly contained in a covered dumpster and the garbage storage area was maintained in a sanitary condition to prevent pests. This had the potential to affect all 118/118 residents residing at the facility.

Inspectors wroteThe facility failed to ensure food was prepared and served to residents at appropriate temperatures, failed to ensure staff performed appropriate hand hygiene during food handling, including with glove use during the preparation of food and handling of clean dishware. These failures had the potential to affect the 113/118 residents who ate food by mouth at the facility.

Inspectors wroteThe facility failed to reasonably accommodate the needs and preferences of a resident by providing only crackers for snacks on a routine basis, even after the resident requested a more substantial alternative. This affected one of two sampled residents, of a total sample of 113 residents who ate food at the facility, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to promote freedom from an accident hazard, the provision of hot coffee without verifying a safe temperature and/or ensuring the use of appropriate cups, for 3 of 5 residents reviewed for accidents, (#1, #4, and #5); and failed to prevent a burn injury for 1 of 3 residents reviewed for skin injuries, (#1), out of a total sample of 5 residents. The facility's failure to identify the untested temperature of hot coffee as a hazard which posed a risk for burns for residents with cognitive and/or physical impairments resulted in actual harm for resident #1 and placed all residents who received untested hot coffee at risk. Resident #1, a physically and cognitively impaired resident, received hot coffee in a Styrofoam cup and accidentally spilled the liquid on his leg. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its abuse and neglect prohibition policy and procedures related to conducting a thorough investigation of an injury of unknown origin to rule out neglect, to determine if reporting was necessary, and to ensure the safety of 1 of 3 residents reviewed for skin injuries, out of a total sample of 5 residents, (#1).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 2 of 2 residents reviewed for respiratory care from a total sample of 35 residents, (#100, #366).

Inspectors wroteBased on observation, and interview, the facility failed to ensure staff donned facial hair restraints correctly and failed to ensure dishware was allowed to air dry before storing.

Inspectors wroteBased on interview, and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 35 residents, (#17).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was prescribed anti psychotic medications had appropriate diagnosis for its use for 1 of 5 residents reviewed for Unnecessary Medications, of a total sample of 35 residents, (#36).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to limited range of motion and contracture care, for 1 of 3 residents reviewed for limited range of motion and positioning (#25), out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable temperature in 1 of 2 shower rooms, ([NAME] I) and failed to provide a safe and homelike environment in 1 of 13 rooms in the 300-hall, (room [ROOM NUMBER]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply splint and carrot cushion to prevent further/worsening contracture for 1 of 4 residents reviewed for Range of Motion (ROM) of a total sample of 53 residents, (#54).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV) medications and care according to standards of practice and plan of care for 2 of 2 residents reviewed for IV care of a total sample of 53 residents, (#17 and #310).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff on the 7 AM to 3 PM shift to provide timely medication administration per professional standards for 14 of 56 residents on [NAME] 1 Unit, (#1,#2, #10,#14, #31, #35, #48, #49, #54, #56, #58, #96, #210, #211).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as ordered, according to accepted professional standards during the 7 AM to 3 PM shifts, on 1 of 2 units for 14 of 56 residents on [NAME] 1 unit, (#1, #2, #10, #14, #31, #35, #48, #49, #54, #56, #58, #96, #210, #211).

Inspectors wroteBased on interview and record review, the facility failed to conduct regular care plan meetings that included residents or their representatives and the required members of the interdisciplinary team for 3 of 5 residents reviewed for care planning of a total sample of 53 residents, (#7, #9, and #26).

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement individualized comprehensive care plan for splints for 1 of 28 residents reviewed for care planning of a total sample of 53 residents, (#54)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fingernail care was provided as needed for 1 of 6 dependent residents reviewed for activities of daily living (ADL) of a total sample of 53 residents, (#54)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders for oxygen therapy included the flow rate for administration for 1 of 1 resident reviewed for oxygen (O2) therapy of a total sample of 53 residents, (#56).

Inspectors wroteBased on observation, and interview, the facility failed to ensure medications were inaccessible to non-authorized staff and residents for 1 of 3 medication carts on the [NAME] I unit.