Vista Pacifica Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention program when: 1. For one of three residents reviewed (Resident 12), the facility did not ensure the oxygen nasal cannula (a plastic device that delivers oxygen through a tube and into the nose) was stored in an appropriate container or bag when not in use; and 2. For 16 of 47 residents reviewed (Residents 2, 5, 6, 8, 13, 16, 20, 26, 28, 30, 31, 36, 39, 40, 46, and 47), annual TB (tuberculosis-a type of contagious respiratory infection) skin test (test used to diagnosed TB) was not conducted timely. These failures increased the potential for the spread of infection to an already medically compromised resident population of 47 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS - a standardized resident assessment tool) assessment was conducted after a significant change in status assessment (SCSA- an assessment that indicates a major decline or improvement in the resident's status), for one of two residents reviewed for resident assessments (Resident 24), when Resident 24 was admitted and discharged from hospice (a specialized form of medical care provided to individuals who are nearing the end of their life and have a prognosis of six months or less to live) care. This failure had the potential for Resident 24 to not receive the care and services necessary to maintain her highest possible level of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Midodrine (a blood pressure medication used to increase the blood pressure) was administered according to the physician's orders, for one of 17 residents reviewed (Resident 34). This failure had the potential to inadequately control Residents 34's blood pressure, which could affect overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period on January 12, 2025. This failure had the potential to adversely affect oversight and direction regarding residents' quality of care and quality of life directly impacting overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required 80 square feet for each resident was met, for 6 of 25 resident bedrooms (Rooms 1, 9, 11, 12, 14 and 26). This failure had the potential to limit the movements of the residents in their rooms, potentially affecting their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for seven of seven residents (Residents 1, 16, 21, 22, 28, 29, and 151) reviewed for range of motion (ROM the full movement potential of a joint), a system or process was in place to: 1. Identify, assess, evaluate, and monitor residents with limited ROM and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to (abnormality and stiffness of the joints); and 2. Provide an appropriate care and treatment to improve, maintain, or prevent contractures and/or limitation with ROM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for five of seven residents (Residents 1, 21, 22, 29, and 151) when: 1. Residents 1, 21, 22, 29, and 151 had limited range of motion (ROM- the full movement potential of a joint) and/or contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to abnormality and stiffness of the joints); and 2. Resident 21 had Apixaban (medication that helps prevent blood clots) These failures had the potential to result in the delay in treatment and care for Residents 1, 21, 22, 29, and 151.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical supervision of the care of each resident by a physician and that orders for the resident's immediate care and needs were provided for seven of seven residents (Residents 1, 16, 21, 22, 28, 29, and 151 ) with limited range of motion (ROM- the full movement potential of a joint), and or contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to abnormality and stiffness of the joints). These failures resulted in the delay in treatment and care for Residents 1, 16, 21, 22, 28, 29, and 151.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 26, 2024, and February 1, 2024. This failure had the potential to adversely effect the oversight and direction regarding the quality of care and quality of life, directly impacting overall health and wellbeing of all residents.

Inspectors wroteBased interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for three out of four residents (Residents 16, 22, and 30). The medications were signed out of the Narcotic and Hypnotic Record (NHR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 5 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) when: 1. a. Resident 19 was administered lurasidone (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of lurasidone; b. Resident 21 was administered Risperdal (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Risperdal; c. Resident 39 was administered Zyprexa (an anti-psychotic medication for schizophrenia and bipolar disorder) and Haldol (an anti-psychotic medication for schizophrenia) without potential adverse effect monitoring documented during use of Zyprexa and Haldol. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Residents 19, 21, and 39) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 19 was administered lurasidone (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of lurasidone; 2. Resident 21 was administered Risperdal (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Risperdal; 3. a. Resident 39 was administered Zyprexa (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Zyprexa; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage, preparation, and distribution of food were in accordance with professional standards for food service safety, when: 1. Food items inside the kitchen refrigerator were not labeled accordingly; 2. Cooking utensil was not in good repair and/or condition; 3. Food containers were not stored properly from a clean environment; and 4. A Dietary Aide did not perform hand hygiene in between tasks. These failures had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 47 residents who consumed food from the kitchen out of a facility census of 48 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI- group of staff working in the facility that helps the facility to self-identify issues, plan to correct, and improve the lives of the residents in nursing home) program was developed to identify, assess, evaluate, and monitor residents with limitations in Range of Motion (ROM- the full movement potential of a joint ) and/or contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to abnormality and stiffness of the joints). In addition, there were no preventive measures in place to provide appropriate care and treatment to improve, maintain or prevent limitations with ROM and/or contractures for residents who were at risk. (See findings under F688). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula (a tube used to deliver oxygen through the nose) was replaced after seven days for two of two residents reviewed for oxygen use. (Residents 19 and 22). This failure had the potential to result in deterioration of the nasal cannula which would allow infectious organisms to grow causing an infection to Residents 19 and 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 21) was free from unnecessary medications when Resident 21 received apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication) without a clear indication for its use; and the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of apixaban. These failures had the potential to result in unnecessary use of medications for Resident 21 and had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two out of seven residents (Residents 24 and 31). The failures resulted in medications not given according to the physician's orders, had the potential for Resident 24 not receiving the full therapeutic effects the medication, and put Resident 31 at risk of receiving more medication than intended by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when the facility staff failed to clean and disinfect a shared glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions during observation for one resident (Resident 1). The failure had the potential for the development and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required 80 square feet was met for 6 of 25 resident bedrooms (Rooms 1,9,11,12,14 and 26). This failure had the potential to negatively affect the quality of life of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents, when several psychotropic medications (used to treat mental illness) were not administered in accordance with the physician's orders, for one of three residents reviewed (Resident 2). This failure had the potential for Resident 2 to have adverse reactions and changes in behaviors related to not receiving the prescribed medications.

Inspectors wroteBased on interview, and record review, the facility failed to obtain and administer medications as ordered by the physician, for one of two sampled residents (Resident 1), when Trulicity injection (medication to treat high blood sugar) was not available to be administered on the scheduled dose. This failure had the potential for Resident 1's blood sugar to not be controlled and could lead to decline in overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environement for the residents and visitors was provided when the dumpster was observed overflowing and was not securely closed with the dumpster lids. This failure had the potential to attract pests, insects, and vermin which could create an unsanitary environment for vulnerable residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a variety of food substitutes and meal alternatives were offered, for five of 44 residents (Residents 8, 39, 10, 44, and 48) who received food from the facility kitchen. This failure had the potential for Residents 8, 10, 39, 44, and 48's dietary intake to be inadequate by not making reasonable effort of adjusting resident's food plan and preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when multiple food items stored in the refrigerator and freezer were not labeled with opened dates or use-by dates. This failure had the potential to place the residents of the facility at risk for food-borne illnesses in a medically vulnerable resident population of 44 residents who consumed food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control were implemented when the facility staff did not wear the proper PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) while inside the PUI (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]) room when: 1. One Certified Nursing Assistant (CNA) was observed not wearing gloves while feeding Resident 11; and 2. One housekeeper (HSKP) was observed not wearing gloves or a gown while cleaning the PUI room. This failure had the potential to result in the transmission of infection to an already vulnerable population of residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the blood pressure was obtained prior to administering the blood pressure medication according to the physician's order, for one of five residents observed during the medication administration (Resident 45). This failure had the potential for Resident 45 to experience low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired wound care medications and supplies were not readily available for use. This failure had the potential for the residents to receive wound care medications and supplies with decreased efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed, for two of 44 residents observed during meal observation (Residents 8 and 41). This failure had the potential for Residents 8 and 41 to not receive the prescribed diet which could compromise their overall medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per resident was met for six of 25 resident bedrooms (Rooms 1, 9, 11, 12, 14, and 26). This failure had the potential to negatively affect the quality of life of the residents.