Vista Post Acute

Inspectors wroteBased on observation, interviews, and record review, the facility had a medication error rate of 13.79% when four medication errors occurred out of 29 opportunities during the medication administration observation for four out of nine residents (Residents 3, 8, 10, and 37). Resident 37 did not receive one medication as scheduled; Resident 8 received insulin with incorrect priming; and Residents 3 and 10 did not receive one medication as prescribed. The failures resulted in the residents not receiving the medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar or blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Kitchen wall had an opening in the wall around the drain; 4. Kitchen backsplash, where dishes were cleaned, had food and black substance buildup; 5. A kitchen cleaning schedule was not maintained according to facility policy; 6. Frozen meat did not have date received, date placed in freezer, use by date, and expiration date; 7. Produce and food were not labeled with use by date and were not rotated with FIFO, First in-First out per facility policy; 8. Food in refrigerator had expired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe proper infection control practices when: 1. A nursing staff failed to perform hand hygiene after touching potentially contaminated surfaces during the medication administration; 2. A nursing staff touched and opened two medication capsules with bare hands; 3. A nursing staff failed to observe the enhanced barrier precautions (EBP) as per facility policy and procedures (P&P) for two residents (Residents 37 and 61) during the medication administration; These failures had the potential for Residents 37, 54 and 61 to be placed at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to facility policy and procedures (P&P) when the nursing staff did not check the tube placement and/or residual volume before medication administration for three of three residents (Residents 10, 37, and 61) who were receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The failure had the potential for complications related to enteral feeding such as aspiration (foreign material into the lungs) due to undetected tube displacement, nausea, vomiting, etc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued and unused controlled medications (medications that can be easily abused and are under strict government control) for three residents (65, 123, and 174) were promptly removed from one of three inspected medication carts. The failure had the potential for medication errors or loss/abuse of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 47) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 47 received quetiapine (Seroquel, an antipsychotic medication) for delusion (fixed, false beliefs that conflict with reality) without documented evidence of delusional symptoms, and without demonstration how these symptoms caused harm to the resident/others or caused significant distress to the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meal assistance for one of five sampled residents ' (Resident 1) when staff did not reposition Resident 1 higher in bed and did not assist in setup of meal tray for 30 minutes during dinner. This failure prevented Resident 1 from finishing dinner because Resident 1 was in an uncomfortable position and could not reach or open food items on the meal tray, which had the potential for weight loss and low blood sugar.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the right of privacy for one of 23 sampled residents (Residents 52) when personal care instructions were posted on the walls of the resident's shared room. This failure had the potential to affect Resident 52's sense of self-worth and self-respect due to the public display of personal care information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an orderly and homelike environment for two of 23 sampled residents (Resident 52 and resident 119), when an old, uncovered sign that showed the name of the previous resident (Resident 42) was not removed from the shared room currently occupied by Resident 52 and Resident 119. This failure had the potential to affect Resident 52 and Resident 119's well-being and cause mental confusion in a setting meant to be their home.

Inspectors wroteBased on observation, interview and record review, the facility failed to verify the physician's wound care treatment order for one of 23 sampled residents (Resident 29) prior to rendering wound treatment. This failure had the potential to not promote the healing of Resident 29's wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 23 sampled residents (14) was referred and was provided podiatry services. This deficient practice resulted in Resident 14 to have pain and at risk of injury because of her long toenails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 27) when Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using a mechanical lift (a mechanical device used to assist with transfer and movement of residents who required support for mobility beyond the manual support provided by caregivers alone) by himself and without assistance. This failure had the potential to result in serious avoidable resident injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain-relieving medication to one of 23 sampled residents (Resident 120) before a Stage 4 pressure ulcer (severe tissue damage that extends to muscles, bones and/or tendons) wound dressing change was rendered. This failure resulted in Resident 120's avoidable, unnecessary pain and discomfort during Resident 120's wound treatment which affected Resident 120's ability to maintain his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for three of three sampled residents (Residents 53, 59, and 62) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. Three of nine emergency kits (e-kit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) inspect the emergency medication kits (e-kits) on a monthly basis in accordance with the facility policy and procedures (P&P). Also, the CP failed to identify and report to the facility medication irregularities during the monthly medication regimen review (MRR) for two of 23 sampled residents (14 and 27). The failures resulted in opened and expired e-kits not being replaced timely for resident use; and undetected medication irregularities had the potential for residents not achieving highest therapeutic outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents (Residents 10 and 27) and a non-sampled resident (Resident 39) were free from a significant medication error when they received insulin (medication to lower blood sugar) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, which would result in uncontrolled high blood sugar for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) did not expire; expired insulin (medication to lower blood sugar) prefilled pens were removed from the medication carts for two of two medication carts inspected; and an opened multi-dose vial had an open date in one of two medication refrigerators inspected. The failure resulted in insulin pens given past the expiration date; and the potential for residents to receive expired medications which would result in unsafe and ineffective use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep two of three treatment carts (a portable cart containing supplies needed for wound care) locked when not in the view of a licensed nurse. This failure had the potential to result in injury to residents, staff, or visitors from unauthorized use of injection needles, scissors, and suture supplies (needles and surgical thread used to sew wounds closed).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure to drugs used to control pain and anxiety were labeled with the correct physician orders for 8 of 11 sampled residents (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). These failures had the potential to result in Residents 51, 106, 52A, 52B, 10, 308, 16, 24, or 7 receiving incorrect medication doses with resultant overdosage or underdosage causing oversedation or ineffective treatment of pain and/or anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. Several food items in the kitchen refrigerator were unlabeled and undated. 2. Expired nutritional supplements were stored on the same shelf as nutritional products designated for current consumption. These failures had the potential to cause food contamination or food borne illness.

Inspectors wroteBased on observation, interview and review of records the facility failed to ensure infection control policies and procedures were followed for three of six sampled residents (Resident 52, 306, and 307) when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to perform necessary hand hygiene during wound care for Resident 52, and did not disinfect scissors used for the wound treatment before storing the scissors. 2. The facility failed to provide required Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) readily available outside the residents room per policy and procedure, and that staff wore the necessary PPE for two of two residents (Resident 306 and 307). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled resident rooms had accurate wall clocks. This failure resulted in emotional distress from not knowing what time it was for two (Resident 306 and Resident 307) of four residents in the rooms with inaccurate wall clocks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for two (Resident 39 and Resident 11) of 23 sampled residents when; 1. the facility did not address Resident 39's complaints of noise. 2. the facility did not replace Resident 11's broken television for over three weeks. For Resident 39 this failure resulted in decreased sleep and rest from excessive noise which caused mental and physical stress. For Resident 11, this failure resulted in less enjoyment of life from not being able to watch his favorite television shows on a screen large enough for him to see the shows.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed assistance with nail care for one of 22 sampled residents (Resident 1) when Resident 1's fingernails were untrimmed with sharp, chipped edges and black substance beneath the nail tips. This failure resulted in Resident 1 appearing poorly groomed with the potential to cause emotional distress and physical discomfort from injuries resulting from scratched skin from chipped nails.

Inspectors wroteBased on observation, interview and record review, for two residents (Resident 56 and Resident 39) the facility failed to inform residents and their responsible parties regarding the current facility visitation policy when: 1. The facility did not notify Resident 56 and her family that in-person visitation was allowed. 2. The facility did not notify Resident 39's Responsible Party 2 (RP 2, an individual responsible for health care decisions for a resident without capacity to make decisions) that in-person visitation was allowed. These failures resulted in feelings of depression and social isolation for Residents 56 and 39.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one (Resident 11) of 22 sampled residents, received sevelamer (a medication that helps control blood phosphorus levels) according to physician orders. The failure to ensure Resident 11 received the correct dose of sevelamer had the potential to result in increased levels of phosphorus in the blood which can lead to decreased bone strength and broken bones.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 16) received a meal at a nourishing and palatable temperature. The failure of dietary staff (Cook 2) to check the temperature of hot food items before plating and serving the meal to Resident 16 had the potential to result in scalds or burns from excessively hot food, or decreased intake and/or food borne illness from a meal cooked and/or served at an inadequate temperature.