Vista Real Post Acute

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan, including appropriate interventions for one of three residents reviewed for quality of care (Resident 1) who repeatedly refused showering. This failure resulted in the lack of individualized interventions to address the resident's hygiene needs and preferences and had the potential to result in poor hygiene, skin integrity issues, and ineffective communication with the responsible party.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective supervision and implement individualized interventions for one of three residents reviewed for elopement risk (Resident 1), who was assessed as high risk for wandering/elopement. This failure resulted in Resident 1 climbing over the facility fence and leaving the facility grounds, placing the resident at risk for serious injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when multiple cardboard boxes were found on the ground outside of the designated container and not stored appropriately. This failure had the potential to attract pests and cause infection control issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure, seven of 14 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 6, 10, 21, 23, 32, 42) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. This failure had the potential to result in the ADs for Residents 1, 6, 10, 21, 23, 32, and 42 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings 1. On June 24, 2025, at 11:16 a.m., an interview was conducted with Resident 6. Resident 6 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one. Resident 6's record was reviewed. [...]

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 three dietary staff members did not follow the manufacturer's instructions for testing the red bucket (sanitizing solution) sanitizer. This failure had the potential to create unsafe and unsanitary kitchen conditions and could result in foodborne illness (stomach illness acquired from ingesting contaminated food).

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of three residents (Resident 28) with dignity when an Activities Assistant (AA) stood over the resident while providing assistance with liquid nourishment during designated snack period. This failure had the potential to negatively impact the safety, dignity, and respect of Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. The Licensed Vocational Nurse (LVN) did not clean and disinfect a blood pressure machine between resident uses. 2. The LVN used gloves that had been stored inside her scrub pocket before administering medication. These failures had the potential to result in cross-contamination, increasing the risk of infection spread among an already vulnerable population of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of three residents reviewed (Resident 2) when reports of food intake below 50% on multiple occasions were not properly communicated to nursing staff, physician (MD), and registered dietitian (RD). This failure had the potential to negatively affect Resident 2 ' s nutritional status and overall medical status.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 2) received continuous supervision and assistance, when the staff assigned to monitor Resident 2 left the resident unattended while he was sitting in a chair and had fallen asleep. This failure had the potential to result in harm to Resident 2, including injury from an unassisted fall.

Inspectors wroteBased on interview and record review, the facility failed for one of three residents (Resident 1) to notify the resident's representative (RP) of a decline in the resident's health status/condition. This failure had the potential to result in the RP not being informed in a timely manner, delaying their opportunity to be present regarding Resident's care at the end of life.

Inspectors wroteBased on interview and record review the facility failed to provide an environment free of physical abuse for one of five residents (Resident 2) when staff did not intervene and redirect Resident 2 away from Resident 3, who had previously alleged that Resident 2 had taken his belongings. This failure resulted in Resident 3 punching Resident 2 on the right side of the face, causing Resident 2 to fall and sustain a laceration (broken skin) and swelling on the right side of the face.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide effective supervision for one of five sampled residents (Resident 2), who had history of exhibiting unprovoked aggressive behavior towards staff members and had history of altercation with another resident. This failure resulted in Resident 2 to be able to hit a resident (Resident 1) on the left side of her face with a plastic plate cover. Resident 1 sustained a black bruise and swelling above the corner of the left upper lip.

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. The [NAME] used a slotted spoon to scoop out meatloaf without measuring the portion when preparing pureed meat during the lunch service on July 8, 2024. (Cross referred F 803) This failure had the potential for four out of four residents who received pureed meat prepared in the kitchen to not meet their nutritional needs, which could lead to nutrition-related health complications. 2. Diet Aide 2 served ice cream instead of diet cookies to Resident 7, who had a physician-ordered renal controlled carbohydrate during the lunch service on July 8, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. The [NAME] did not follow puree recipes when preparing pureed diet during the lunch service on July 8, 2024; (Cross referred F 802) This failure had the potential for 4 out of 4 residents who had physician ordered pureed diets, as the pureed food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 2. The [NAME] served biscuit instead of wheat roll for Carbohydrate Control diet Residents during the lunch service on July 8, 2024; This failure had the potential for 12 out of 12 residents who had physician-ordered Carbohydrate Control diets, as the food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was buildup found on the ice maker; 2. Wear and tear were observed on the mixer in the kitchen; 3. The milk refrigerator's gasket was found to have black grime; 4. [NAME] grime was found on equipment; 5. Open food items were found on exposed to the air; 6. Three serving scoops were stored wet with other dry scoops, and one plastic container was stacked wet with other dry containers; 7. The vent hoods were covered with grease and dust; 8. The ceiling above the steam table was covered with dust. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 51 out of 52 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when: 1. Resident (55) was observed to have a pair of black shoes and blue pants on top of a commode (chair with a built-in toilet seat). 2. The Activity Director (AD) was observed to have long artificial nails when providing direct care to residents. These failures had the potential to increase the risk of transmission of infectious disease (disorders caused by organisms) to vurnerable residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to contain waste in a closed container, and provide a comfortable homelike environment for three of six residents reviewed (Residents 30, 42, and 43) when: 1. Multiple discarded medical equipment and non-medical materials surrounding the outside disposal bins. This failure had the potential to attract insects and rodents, presenting a health risks to the vulnerable population in the facility. 2. The window blinds in resident rooms were damaged. This failure had the potential to cause disruption of sleep, inability to properly control sunlight leading to increased heat.

Inspectors wroteBased on interview, and record review, the facility failed for two of six residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 4 and 5) to: 1. Ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record; and 2. Verify if the resident did have an advance directive or if the resident representative was provided information regarding formulation of the advance directive. These failures had the potential for Residents 4 and 5's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents wishes regarding their medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representatives (RP) and Office of the State Long-Term Care Ombudsman (LTC Ombudsman) of a transfer for one of three residents (Resident 57) reviewed for closed records. This failure had the potential to result in the RP and LTC Ombudsman not to be informed about Resident 57's plan of care and condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician recommendation for wound treatment was transcribed to an actual physician order for one of two residents (Resident 23) reviewed. This failure resulted in a gap in the communication regarding the physician's recommendation which affected the implementation of the recommended care or treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for one of six sampled residents (Resident 42). This failure had the potential to cause skin breakdown and infection for Resident 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician order for respiratory care and treatment for one of one resident reviewed for oxygen administration (Resident 56). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and a decline in Resident 56's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental referral and dental care services for one of one resident reviewed for dental (Resident 55). This failure had the potential to negatively effect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician orders were followed for one of four sampled residents (Resident 7) during a dining observation when: 1. Resident 7, who had a physician order for thin liquid (liquids that take little or no effort to drink) received honey- thick (slightly thicker, like honey or a milkshake) liquid during lunch on July 8, 2024. This failure had the potential to result in Resident 7 becoming discouraged with his fluid intake, further compromising his nutritional and medical status. 2. Resident 7, who had a 120 ml fluid restriction (liquid allowed to drink) for the lunch meal per physician order, received 240 ml fluid during lunch on July 8, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was in place for the kitchen when house flies were observed flying and landing in the kitchen and dining hall. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) among the facility residents who eat food prepared in the kitchen.

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 one of four residents (Residents 1) when: Resident 1 had a documented social history assessment indicating the presence of experiencing trauma (severe emotional or mental distress caused by an experience). This failure had the potential to result in the re-traumatization (a relapse into a state of trauma, triggered by some subsequent event) of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), was provided trauma informed care. This failure had the potential to result in re-traumatization of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown source within 2 hours to California Department of Public Health (CDPH) after the facility was made aware of the injury, for one of three sampled residents (Resident 3). This failure had potential to result in further injury for Resident 3, affecting resident's physical, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made for six of nine sampled residents (Residents 1, 2, 3, 4, 5, and 6). This failure had the potential to place Residents 1, 2, 3, 4 , 5, and 6 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control practices for COVID-19 (a highly infectious respiratory virus), for three of five sampled employees, when: 1. Two Certified Nursing Assistants were allowed to work after tested positive for COVID-19; and 2. One CNA (CNA 1) had not been fit tested with the N-95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) used during direct care for COVID-19 positive residents. These failures had the potential to increase staff and resident exposure and transmission of COVID-19 virus causing illness to vulnerable population. Findings 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored in accordance with the professional standards for food service safety when: 1. Multiple food items in the dry storage room were not labeled with received by date or open date as per facility policy and procedure; 2. Five pounds thickener in a bucket was not labeled with an open date; 3. Multiple rotten food items were in the walk-in refrigerator available for use; and 4. Six loaves of bread and 6 pieces of bun were stored outside the walk-in refrigerator available for use. These failures had the potential to result in contamination of food, causing food-borne illnesses to vulnerable population of 46 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food portion sizes were followed as indicated in the spreadsheet. This failure had the potential to result in not meeting the nutritional needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the puree meal was prepared at an appropriate consistency. This failure had the potential to result in decreased resident's satisfaction, decreased appetite, and decreased oral intake for six residents on puree diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the call light was within reach for one of 46 residents (Resident 3). This failure has the potential to result in resident not being able to call for assistance.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and evaluation in the care plan for one (Resident 41) of six residents reviewed for PASRR (Pre-admission Screening & Resident Review- a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs). This failure had the potential for Resident 41's special needs not to be met in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to follow-up on a Level II PASRR evaluation (Pre-admission Screening & Resident Review-a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs), for one of six residents reviewed for PASRR (Resident 4). This failure had the potential to result in admitting residents that were not appropriate in the nursing facility and for Resident 4 not to receive the appropriate services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed to address Activity of Daily Living (ADL's) for one of three residents reviewed for care planning (Resident 3). This failure had the potential for the resident not to be able to attain or maintain his mental, physical, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two of 15 residents reviewed (Resident 18 & Resident 50), when: 1. Resident 50, receiving an Insulin Detemir (medication to control blood sugar), did not have blood glucose monitoring. This failure had the potential to result in not being able to track the effect of the medicine which could lead to unmanaged blood sugar increasing the risk for health complications. 2. Resident 18's skin condition was not appropriately assessed. This failure had the potential to result in delayed treatment leading to skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the need for the use of floor mat to ensure safety for one of one resident reviewed for fall (Resident 17). This failure had the potential to result in not being able to determine the appropriate intervention to ensure safety for Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of oxygen was prescribed by the physician for one of one resident ( Resident 20). This failure has the potential for the resident not to receive therapeutic benefit for oxygen use which could result in serious health complications.

Inspectors wroteBased on interview, and record review, the facility failed to re-evaluate the effectiveness of the current pain medication regimen for one of one resident reviewed for pain (Resident 18). This failure had the potential for the resident's pain not to be managed which could affect the resident's physical and psychosocial functioning.

Inspectors wroteBased on interview and record review, the facility failed to act on the pharmacy consultant's recommendation for the use of gabapentin (treats seizures [uncontrollable shaking]), for one of five residents reviewed for unnecessary medications (Resident 30). This failure had the potential to result in adverse consequences for the use gabapentin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure regarding food safety requirements when: 1. The resident's perishable food in the nursing station refrigerator was not date labeled. This failure had the potential to result in food borne illnesses to vulnerable population. 2. Food and drink at the bedside, brought by the family members/caregivers, were not consistently checked by the staff to ensure proper storage and consumption before the date indicated in the packaging for Residents 18 and 33. This failure had the potential for the resident to experience food poisoning such as stomach cramps, diarrhea, nausea, and vomiting.