Vista Ridge Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for one of seven residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse by CNA A. This failure could place residents at risk for abuse or neglect that could lead to serious harm.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 5 residents (Resident #5) reviewed for reporting according to the facility policy. The facility failed to follow the facility's policy to report allegation of abuse when Resident #5 made an outcry to the Psychologist regarding sexual abuse from her FM on 3/24/26. This failure could place residents in the facility at risk of abuse and lack of timely reporting of incidents. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which meant she had moderate cognitive impairment. Resident #5 had unclear speech, sometimes made herself understood and usually understood others. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to other officials (including the State Survey Agency where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 out of 5 residents (Resident #5) reviewed for abuse or neglect. The facility failed to report an allegation of abuse to the State Survey Agency (HHSC) after they learned Resident #5 had made an allegation of sexual abuse against her FM on 3/24/26. These failures could place residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychological harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. The facility failed to submit a completed investigation regarding the allegation sexual abuse of Resident #5 by her FM to the State Survey Agency. This failure placed residents at risk of further abuse and a lack of oversight by the State Survey Agency. Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure stored canned goods had uncompromised seals and were free from dents. The facility failed to ensure the handwashing sink #2 of #2 garbage receptacle contained only paper towels. These failures could place residents at risk for food-borne illness, cross contamination, and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of four staff members (MA A, MA B and CNA C) and six of six residents (Resident #71, #89, #4, #13, #88 and #76) reviewed for infection control procedures. 1. The facility failed to ensure MA A performed hand hygiene after direct contact with Resident #71, while serving meals in the dining room. 2. The facility failed to ensure MA A disinfected the blood pressure cuff in between vital sign checks for Resident #89 and Resident #4. 3. The facility failed to ensure MA B disinfected the blood pressure cuff in between vital sign checks for Resident #13 and Resident #88. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 13 residents (Resident #55, and Resident #71) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #55, and Resident #71, at the same time the other residents were served the lunch meal. These failures could place residents at risk of feeling like their dignity was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 5%, based on 34 opportunities, which involved 1 of 7 residents (Residents #47) and one of two staff (MA A) observed during medication administration for medication error. 1. MA A failed to administer Resident #47's Miralax Oral powder 17grm (for constipation) with the appropriate amount of fluid. 2. MA A failed to confirm Resident #47's MiraLAX Oral powder 17grm (for constipation) was administered. MA A left the cup of medication with Resident # 47. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #71) reviewed for food and nutrition services. The facility failed to provide Resident #71 with her regular ground foods (mechanically altered diet that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on her meal ticket on 03/17/2026. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse call system was accessible for residents to call for staff assistance through a communication system which relays the call directly to a staff member of a centralized staff work area for seven of ten residents (Residents #1, #2, #4, #5, #6, #7, and #9) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Residents #1, #2, #4, #5, #6, #7, and #9's rooms were in a position accessible to the residents on 10/07/25 on the 200, 300, and 400 halls. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of three residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 had physician orders for the bolster mattresses on her bed. This failure could place residents at risk of not having an environment free from physical restraints.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of six residents (Resident #3, #8, and #10) reviewed for respiratory care. The facility failed to ensure Resident #3 and #8's nebulizer mask was properly stored in a bag when not in use on 10/07/25. The facility failed to ensure Resident #10's CPAP mask was properly stored in a bag when not in use on 10/07/25. These failures could place residents at risk for respiratory infection and not having his respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of five residents reviewed supervision. The facility failed to ensure Resident #1 (who was ordered a pureed diet and was a known aspiration risk) was provided with adequate supervision during the lunch meal on 04/01/25. Resident #1 was sat at a table with another resident who offered her a cookie, which Resident #1 accepted and ate, which led to her coughing several times before finishing the cookie. Five staff were in the dining room but no one was supervising the resident at the time to ensure safety or noticed she was eating outside her modified diet texture. An IJ was identified on 04/01/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's nasal cannula nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly. 2. The facility failed to ensure Resident #1's nasal cannula and humidifier were changed weekly. 3. The facility failed to ensure there was an Oxygen in Use sign outside Resident #1's door. 4. The facility failed to ensure Resident #2's nasal cannula was stored properly. 5. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #1 reviewed for Care Plans. The facility failed to ensure Resident #1 Care Plan was reviewed and updated quarterly. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #1) of five resident reviewed for person-centered plans of care. The facility failed to include Resident #1 in his Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the confidentiality of personal health care information for one (CMA B) of three staff observed for confidentiality of records. The facility failed to ensure CMA B locked and closed the laptop during the medication pass exposing all resident on the hall's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a sanitary environment for 1 (Residents #1) of 4 residents reviewed for environmental conditions. The facility failed to ensure Resident #1's bed was made with clean linens and was not wet and did not contain urine stains. The failure placed residents at risk for unsanitary living.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for one of four halls (Hall 300) reviewed for medication storage. On 4/16/2024, the facility failed to keep Medication Cart 1 locked on Hall 300. These failures placed 27 residents on Hall 300 at risk of drug diversions or misuse of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for two (CNA A and CNA B) of 8 CNAs reviewed for infection control. CNA A and CNA B failed to wear adequate PPE while repositioning COVID-19 positive Resident #1. CNA A failed to wear adequate PPE while delivering and setting up COVID-19 positive Resident #2's breakfast tray. CNA A and CNA B failed to perform hand hygiene while delivering and picking up breakfast trays from residents on the 300 hall. This failure placed residents at risk for infection and result in decline in health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 9 of 20 rooms (Room # 106, 110, 112, 114, 118, 401, 408, 405, and 418), observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms and handrails were cleaned and sanitized. These deficient practices could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #11, Resident #31, Resident #3, and Resident #16 of six residents observed for infection control. The facility failed to ensure that Resident #11's nasal cannula was off the floor. The facility failed to ensure CMA (certified medication aide) C sanitized the blood pressure cuff between Resident #3, Resident #16, and Resident #31. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #11) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #11's rooms was in a position that was accessible to the resident. This failure could place the resident at risk of being unable to have their needs met or obtain assistance in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #11) of six residents reviewed for admission orders. The facility failed to obtain physician orders for oxygen supplement for Resident #11 at the time of admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 4 (Resident,#7, #11, #22, and #82) of 12 residents reviewed for Care Plans. The facility failed to ensure Resident #11, and Resident #22 were care planned for oxygen administration. The facility failed to accurately assess Resident #7's diagnosis of malnutrition by not including the resident's physician orders for weekly weigh-ins as an intervention on the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #7) reviewed for assisted nutrition and hydration. The facility failed to assess Residents #7's weight on a weekly basis per physician orders, and the resident experienced more than a 5% weight loss in a month. This failure could place resident at risk of experiencing a decline in health due to malnutrition.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Resident #11, #32, #64) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #11's and 64's nasal cannulas were bagged and failed to change Resident #32's humidifier on the oxygen concentrator, which exceeded the facility policy of 7 days. These failures could place the residents at risk of not having their respiratory needs met.