Vista Pacifica Center

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, for one of seven residents reviewed for abuse (Resident 1), when Resident 2 struck Resident 1 a second time following an earlier physical altercation. The facility failed to ensure Resident 2 was adequately separated from Resident 1 following the initial incident to prevent further incidents. This failure resulted in Resident 1 being subjected to second physical assault and had the potential to negatively affect the resident's physical, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Two Dietary staff were unable to demonstrate the correct concentration for the red bucket sanitizer solution. 2. One Dietary staff did not wear gloves while sanitizing the food preparation table. 3. Four Dietary Staff could not demonstrate the proper procedure for testing dish sanitization. These failures had the potential to cause food borne illness (stomach illness acquired from ingesting contaminated food) to the residents in the facility.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to maintain a sanitary environment, prepare, and serve food in accordance with professional standards for food service safety when three cutting boards with deep indentations were found in the kitchen. This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe accident-free environment when the facility did not offer a smoking apron during smoking break for one of two residents (Resident 10). This failure had increased the potential for the resident to experience accidents and injury while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed and used appropriately to meet the needs of the resident when: 1. One injectable antipsychotic medication (used to manage schizophrenia symptoms such as delusions, hallucinations, paranoia, and/or altered sense of reality) was not administered every 28 days as prescribed by the physician and per manufacturer's prescribing information. 2. One Oral Emergency Ekit did not have an accurate expiration date on the outside of the kit. These failures had the potential for residents to receive ineffective or excessive medication therapy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper storage of one medication in accordance with manufacturer's specifications by not protecting it from light. This failure had the potential for one resident to receive ineffective medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's food preference was honored for one of three residents reviewed for nutrition (Resident 22). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment when the Laundry Aide (LA) did not clean the lint trap in the dryer resulting in the lint accumulation. This failure had the potential to result in a fire hazard, putting residents at risk.

Inspectors wroteBased on interview and record review, the facility failed, for one of five sampled residents (Resident 1) to notify Resident 1's representative (conservator) following an incident involving contraband ( a metal fork) found in the resident's room. This failure had the potential to exclude the resident's representative from being involved in the care planning and decision-making regarding resident's safety and psychosocial status.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan and implement appropriate interventions for one of five sampled residents (Resident 1) after the resident was found with contraband (a metal fork) under his mattress. This failure had the potential for Resident 1 to retain or collect additional contraband without staff knowledge, placing the resident and others at risk for harm.

Inspectors wroteBased on interview and record review, facility failed to ensure the resident was treated with dignity and respect for one of three sampled residents (Resident 1), when Mental Health Worker (MHW 1) did not assist the resident after he fell from his wheelchair and failed to provide support when the resident dropped his cigarette. This failure resulted in Resident 1 becoming angry and agitated with staff member.

Inspectors wroteBased on interview and record review, the facility failed to report the neglect for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within 2-hours. Resident 1 was denied a cigarette and left without assistance back into his wheelchair by Mental Health Worker (MHW) 1. This failure had the potential to result in Resident 1 to remain at risk of further harm and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement ongoing infection surveillance monitoring for suspected scabies (a highly contagious skin condition caused by mites that burrow into the skin), for six of six residents (Resident 1, 2, 3, 4, 5, and 6). This deficient practice had the potential for a delay in the care and treatment and possible spread of infection throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP - professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) completed the required specialized training for the IP certification program. This failure resulted in the Infection Control and Prevention Program of the facility not having the benefit of a fully qualified and competent IP having the potential to negatively affect the quality of care provided to all the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three residents sampled (Resident A) did not receive candy infused with cannabis (dried leaves and flowering tops of the Cannabis sativa or Cannabis indica plant which contains active chemicals that cause drug-like effects all through the body) while at facility. This failure had the potential to cause untoward effects of the cannabis to Resident A's overall health and mental condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate infection control practices in preventing the transmission of the coronavirus infection (COVID-19 - illness caused by a virus that can be transmitted from person to person) were implemented in accordance with the facility's policy and procedure and Center for Disease Control (CDC) guideline, when the residents and Healthcare Personnels (HCP/staff) were not tested for COVID-19 timely. This failure resulted in a delay in the identification of residents and HCP who were COVID-19 positive, thereby delayed the implementation of infection control measures to prevent further transmission of COVID-19 in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse by a resident (Resident A) towards another resident (Resident B) was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. This failure had the potential to result in a delay of the implementation of appropriate actions, provisions, and protections to the residents and placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. 38 insulated plate covers, seven insulated plate bases, and three full sheet metal pans were stacked and stored wet found in the readily to use storage areas; 2. Two various size of cooking pans had dry and heavy black substance buildups on the cooking surfaces and readily available for use; 3. The ice machine was not clean and sanitized properly per the manufacturer's recommendations; 4. The sanitizer concentration was not at the correct range for the manual ware washing in the three-compartment sink; 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. The facility's policy and procedure on Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was followed, for 16 of 26 residents reviewed for AD (Residents 1, 23, 36, 42, 51, 53, 54, 57, 65, 67, 70, 75, 76, 83, 86, and 106) when there was no documentation whether the resident chose to complete or decline to formulate an AD when it was offered; and 2. Information regarding formulating an AD was provided to the resident representative (RR), for one of 26 residents reviewed for AD (Resident 16), who did not have the capacity to understand or make a decision for himself. These failures had the potential for the residents to not exercise their right to complete or not complete an AD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a diet that is usually a modification of a regular diet. It is modified or tailored to fit the nutrition needs of a particular person. It could be a part of the treatment of a medical condition and normally prescribed by a physician) for lunch on April 18, 2022, and lunch on April 19, 2022, when: 1. Eight residents (Residents 6, 31, 34, 54, 56, 61, and 66) who were on NAS (no added salt) diet received salt packets with their meals; and 2. Four residents (Residents 39, 69, 75, and 104) who were on fortified (enhanced food addition to increase calories and/or protein) diet received regular mashed potatoes with their meals. These failures had the potential to result in compromising the medical and nutrition status of those 11 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another), when one facility staff was observed wearing long artificial fingernails while preparing medications for the residents. This failure increased the risk of cross-contamination which could result in the development and transmission of infections to a vulnerable population of 106 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to address the use of anticoagulant (medication to prevent blood clots) medication, for one of five residents reviewed for unnecessary medications (Resident 58). This failure had the potential for Resident 58 to be at risk of bleeding or adverse reactions from the medication and to not be managed and provide immediate appropriate treatment and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct amount of eye drop medication was administered according to the physician's order, for one of six residents (Resident 103) observed during medication administration observation. This failure resulted in Resident 103 to not receive the prescribed amount of the eye drop medication and had the potential for complications such as loss of vision and blindness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate foot care and treatment was provided, for one of two residents reviewed (Resident 65), when the facility did not provide diabetic shoes with plastic inserts as ordered by the physician. This failure had the potential for Resident 65 to develop complications on the feet related to diabetes mellitus (DM - abnormal blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required supervision during smoke break were monitored closely, for one of 97 residents (Resident 16) observed for smoking. This failure had the potential to place Resident 16 at risk for injuries and accidents related to smoking.

Inspectors wroteBased on interview and record review, the facility failed to ensure the depakene level (laboratory test done to check the depakene [medication to treat impulse disorder] level in the blood) were completed as ordered by the physician, for one of 26 residents reviewed (Resident 46). This failure had the potential for Resident 46 to not be monitored for the therapeutic level of the depakene medication needed to effectively address his impulse disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's food preference was honored, for one of residents observed during meal observation (Resident 6). This failure had the potential for Resident 6's food intake be affected and could result in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice when medications were not administered immediately after they were prepared and were not documented as given immediately after they were administered, for nine of nine residents observed during medication pass (Residents 26, 64, 48, 61, 72, 42, 60, 27, and 32). These failures had the potential to result in medication errors.

Inspectors wrote3. On January 24, 2020, the record for Resident 32 was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses including hypertension and hypothyroidism (low level of thyroid hormone in the blood). The document titled, Order Review Report, for January 2020, included a physician's order, dated July 31, 2018, which indicated, Lopressor (a medication to lower blood pressure) Tablet Give 25 mg by mouth two times a day .Hold if SBP < 100 HR < 60 . The MAR, for December 2019, indicated lopressor was administered to Resident 32 on December 8, 9, and 28, 2019 (three times), when Resident 32 had SBP readings below 100. The MAR, for January 2020, indicated lopressor was administered to Resident 32 on January 1, 3, 4, 15, and 17, 2020 (five times), when Resident 32 had SBP readings below 100. On January 24, 2020, at 1:31 p.m., LVN 2 was interviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu for low fat low cholesterol diet was followed, for 12 of 12 residents who were on low fat low cholesterol diet. This failure had the potential for the residents to not receive the appropriate diet which could compromise their nutritional status and may lead to medical complications.