Vista Ridge Senior Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for CR 8 (CR #1, CR #2, CR #3, CR #4, CR #5, CR #6, CR #7, CR #8) of 8 CR reviewed for food and nutrition services. 1. The facility failed to have a system in place for reheating resident food items brought in from outside sources to ensure safe food handling and were not allowing residents to bring in food from outside sources.2. The facility failed to accurately document temperature recordings of nourishment station refrigerators. These failures could place residents at risk for foodborne illnesses.

Inspectors wroteBased on observations, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 4 pureed diets of 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure [NAME] G refrained from adding an unmeasured amount of liquid to southwestern style chicken pureed during meal service on August 20, 2025. This failure could place all 4 residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in the walk-in refrigerator, freezer and in the dry food pantry area on 8/19/2025, 8/20/2025, and 8/21/2025. 2. The facility failed to discard expired food items located in the walk-in refrigerator and in the dry food pantry area.3. The facility failed to ensure that dietary staff [NAME] G on 8/20/2025 at 3;35 PM, practiced appropriate hand hygiene and glove use when necessary, during food preparation activities, such as between handling raw fish and other foods, to prevent cross-contamination. These failures could place all residents who received meals from the kitchen at risk of foodborne illnesses.

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 3 of 5 residents (Resident #42, Resident #20, and Resident #57) reviewed for infection control. 1. The facility failed to ensure CNA A was following prescribed Enhanced Barrier Precautions by not putting on a gown before providing peri-care to Resident #42. 2. The facility failed to ensure CNA B was cleansing male residents properly and conducting hand hygiene and glove change during peri-care for Resident #20. 3. The facility failed to ensure CNA D was conducting proper Foley catheter care for Resident #57. [...]

Inspectors wroteBased on observations and interviews, the facility failed to post, in a form and manner available for all residents and resident representatives, the required contact information for the public and the entire facility including telephone number of the Long-Term Care Ombudsman program for the facility's postings for 1 of 1 facility reviewed for resident rights. The facility did not have the Ombudsman Program sign posted with contact information. This failure could affect resident representatives and place residents at risk of not having access to a written description of their rights, advocacy groups, and a decreased quality of life by not having access to Ombudsman information for resources.

Inspectors wroteBased on observations, interviews, and record review. The facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility. The required documents were not posted in a location readily accessible and visible to all residents, their legal representatives, or family members. This failure could place all residents of the facility at risk of limited' rights to access information regarding the facility's compliance with state and federal requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a temperature range of 71' to 81' Fahrenheit for 38 (room numbers 2, 6, 8, 9, 11, 14, 16, 17, 23, 25, 28, 31, 32, 33, 46, 48, 49, 50, 51, 55, 64, 65, 66, 68, 72, 73, 74, 75, 78, 81, 84, 86, 87, 91, 94, 96, 97, 98) of 58 rooms on the 1st and 2nd floor reviewed for temperature of the environment, in that: The facility failed to ensure resident rooms had working heaters, working thermostats, and residents were warm. The facility failed to screen residents for signs and symptoms of hypothermia. For an unknown period of time: Rooms 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents did not have working heaters. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment and no more than 21 days after admission for two (Resident #1 and #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's and #2's comprehensive care plans were completed within seven days after completion of their comprehensive assessments. This deficient practice could place residents at risk of not receiving assistance with activities of daily living and sustaining a serious injury, impairment or death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident had the right to be free from abuse and neglect for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to ensure Resident #1 was free from abuse by his SO/AP when the facility neglected the interventions of Resident #1's care plan. The facility failed to follow the interventions in Resident #1's care plan, such as, keeping the Resident's door open during visits with SO/AP to keep the resident safe. This resulted in allegations that the SO/AP physically and verbally abused Resident #1. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/2024 at 1:30 PM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement their written policies and procedures to report, prohibit, and prevent abuse for one (Resident #1) of five residents reviewed for developing and implementing abuse and neglect policies, in that: The facility failed to implement abuse policies and procedures when they failed to protect Resident #1 from being abused by his SO/AP. The facility failed to report and investigate all suspected abuse and/or aggressive behaviors when staff reported observing SO/AP slap, hit, punch, grab, kick, yell, and shake Resident #1 and reported suspicious bruises, skin tears, and a burn on Resident #1's body and abdomen. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2(Residents #14, and # 58) of 16 residents reviewed for care plans. The facility failed to ensure Resident #14's comprehensive care plan was updated when wound care was ordered to his left knee. The facility failed to ensure Resident # 58's comprehensive care plan was updated when the external feeding was discontinued. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: The facility failed to ensure foods were safely stored, labeled, and dated in the refrigerator. This failure could place residents at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates the catheterization is necessary for 1 of 5 residents (Resident #22) reviewed for incontinent and catheter care. The facility failed to obtain physician orders for Resident #22's indwelling catheter, catheter care, and maintenance. This failure could place residents at risk of infection or accidental dislodgement.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #56 had a preexisting mental illness for which an antipsychotic medication (Seroquel) would be warranted. This failure could place residents at risk for unnecessary psychotropic drug use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse staffing information was posted on a daily basis and included the total number and the actual hours worked by licensed and unlicensed nursing staff for 3 of 5 days (07/26/24, 07/27/24, and 07/28/24) reviewed for nurse staffing and the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months. 1 The facility failed to ensure the Daily Staffing log contained the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical or vocational nurses, and certified nurse aides on 07/26/24, 07/27/24, and 07/28/24. 2 The facility failed to maintain the nurse staffing data from February 2023 through July 31, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 3 of 6 Residents (Resident #28, Resident #142 and #146) reviewed for medication administration in that: 1. Resident #142 was observed with 4 pills in a medication cup, an open box of over-the-counter allergy pills, a container of nasal spray and an open package with a lidocaine patch at the bedside. 2. Resident #146 was observed with a prescription box of Ondansetron (prescribed to prevent nausea/vomiting) and a prescription bottle of Trazadone (prescribed for treatment of depression and used as a sedative) at the bedside. 3. Resident #28's breathing treatments were documented as administered at 9:21 a.m. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for 1 of 7 residents (Resident #192) reviewed during the medication pass for medication labeling, and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 3 of 4 medication carts (nursing cart 1, medication cart 2, and nursing cart 3) medication storage in that: 1. The pharmacy label on Resident #192's insulin pen did not match the dosage prescribed by the physician. 2. Nursing cart 1, medication cart 2, and nursing cart 3 were unlocked and unattended at various times. [...]

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 for 1 of 1 facility reviewed for dietary sanitation in that: The facility failed to ensure the emergency water storage was located at least 6 inches above the ground. The facility failed to ensure the emergency food storage was located at least 6 inches above the ground and 18 inches below the ceiling of the storage room. The facility failed to ensure 2 ice makers were maintained for cleanliness. The facility failed to remove expired food found within 3 of 6 unit refrigerators. The facility failed to ensure 2 of 6 unit refrigerators operated below 41 degrees Fahrenheit. The facility failed to ensure 1 of 6 unit refrigerators maintained complete temperature logs. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 2 of 15 Residents (Resident #142 and Resident #193) reviewed for accidents and hazards, in that: 1. The facility failed to prevent Resident #142 from having cigarettes and a lighter in a drawer attached to the bedside table next to the resident's bed and over the counter medications on the bedside table. 2. The facility failed to prevent Resident #193 from having a box cutter in his room. These deficient practices could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record reviews, 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 1 of 2 residents (Resident # 144) reviewed for infection control practices, in that: CNA D failed to utilize appropriate infection control practices when entering Resident #144's room who was on isolation for an infection. This failure could place residents on contact isolation for infection at risk for spreading the infection or a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 2 Residents (Resident #59) reviewed for transmitting assessments in that: Resident #59's quarterly MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 6 residents (Resident #28) reviewed for pain management in that: Resident #28 requested pain medication from staff and had to wait 2 hours and 45 minutes for a nurse to assess her for pain and administer pain medications. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly, for 1 of 1 trash compacter reviewed in that: The trash compacter had encrusted black dirt and grease built up around the entire perimeter of the trash compacter restricting access. This failure posed a sanitary and safety hazard that could result in the attraction of vermin and affect all resident residing in the facility by exposing them to germs and diseases carried by vermin and rodents.