Vista View Post Acute

Inspectors wroteBased on interview and record review, the facility failed to honor resident rights for 1 of 4 sampled residents (Resident 1) when vaccinations were administered to Resident 1 without his consent. This failure had the potential for Resident 1 to experience unwanted side effects from the vaccinations, and emotional distress from not having his rights/preferences honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to safeguard the resident personal property for one of the two sampled residents (1). As a result, the resident credit card was missing, and a report of unauthorized purchases were charged from Resident 1's credit card. This failure had cause emotional and psychological stress to Resident 1 and may affect the client's trust relationship with the staff. On 7/16/25 at 10 A.M., an unannounced visit at the facility was conducted to investigate a complaint related to a suspicious activity charges on Resident 1's credit card. Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a condition in which bacteria invade and grow in the urinary tract), per the facility's admission Record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure respect and dignity was provided to one of three sampled residents (Resident 2) when a certified nursing assistant (CNA) opened resident's drawer without permission and said inappropriate words towards Resident 2. This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to notify and confirmed bed hold notice to the resident's family representative upon transfer to an acute care facility (hospital) for one of three sampled residents (Resident 1). This failure resulted in Resident 1' s family representative confusion related to bed hold payment.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain the blinds in 5 resident rooms ( Rooms 107, 112, 130, 131, and 138) of 30 resident rooms on the first floor of the facility in good condition.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #104) of 2 sampled residents reviewed for PASARR.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to resubmit a level I preadmission screening and resident review (PASARR) to the appropriate state-designated authority for 1 (Resident #81) of 2 sampled residents reviewed for PASARR.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to post the actual hours worked by staff directly responsible for resident care for 12 of 12 shifts reviewed. This deficient practice had the potential to affect all residents who currently resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure choice was offered to accomodate a preference for a shower for one resident (Resident 304). This failure had the potential to cause psychological harm to Resident 304. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). On 4/7/25 at 10:20 A.M., an interview with Certified Nursing Assistant (CNA) CNA 1 was conducted. CNA 1 stated on 3/21/25 in the morning, she and CNA 2 went into Resident 304 ' s room and told Resident 304 she was getting a shower then immediately transferred from the bed to the shower. CNA 1 stated during transfer, Resident 304 had urinated on herself and bowel movement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure privacy was maintained for one of one resident (Resident 304) when the two CNAs (1, 2) left Resident 304's naked body exposed during the delivery of care. This failure violated Resident 304's right to dignity and privacy. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). An interview on 4/7/25 at 11:20 A.M., with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she had seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses (LN) had specific competencies and training related to Central Venous Catheter site (CVC- a soft plastic tube inserted into a vein to provide vascular access for hemodialysis [a treatment that filters waste and excess fluid from the blood of people whose kidneys were not functioning properly] for 5 of 7 licensed nurses (LN). This failure had the potential to result in inaccurate assessment and delayed care and treatment of a resident with a CVC line.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75) reviewed for abuse and neglect, was free from physical and verbal abuse and neglect when: 1. Certified nursing assistant (CNA) 1 handled Resident 75 in a rough manner during incontinence (an inability to control the release of urine or feces) care. Furthermore, CNA 1 did not stop providing care when Resident 75 requested for her to stop. 2. CNA 1 told Resident 75, No one likes you here. You complain too much, and called the resident a racist. 3. CNA 1 did not clean Resident 75 after an incontinence episode as per the resident's request. As a result of these failures, Resident 75 experienced physical pain and was in fear of CNA 1. The day after the incident with CNA 1 (6/17/21), Resident 75 felt upset and stressed, lacked her usual appetite, was nauseous, and vomited.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. These failures had the potential to impact the quality of care delivered to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement action plans related to the following: 1. Baseline care plans were not consistently developed to address resident diagnoses, care, and treatments. (cross reference F-Tag 655) 2. Resident specific care plans were not consistently developed. (cross reference F-Tag 656) 3. There was not sufficient staffing to respond to resident requests in a timely manner. (cross reference F-Tag 725) These failures had the potential to affect the health and safety of the residents.

Inspectors wroteBased on observation, interview and document review the facility failed to provide sufficient staff to meet the needs of seven residents (Residents 3, 12, 17, 25, 88, and Confidential Residents [CR] 1 and 2). As a result residents 3, 12, 17, 25, 88, CR 1 and CR 2 did not receive care in a timely manner, putting them at risk for skin break down and creating unnecessary fear. In addition, Resident 17 did not receive wound treatment consistently due to insufficient staffing.

Inspectors wroteBased on observation, interview, and record review, the facility's medical director (MD) failed to ensure medical care was provided to residents according to acceptable standards of practice for the following: - Development and Implementation of Care Plans (See F-Tag 656) - Quality of Care/Treatment (See F-Tag 684) - Accidents and Hazards (See F-Tag 689) - Dialysis Assessments (See F-Tag 698) - Sufficient Nursing Staff (See F-Tag 725) - Pharmacy Services (See F-Tag 755) - Medication Errors Greater than Five Percent (See F-Tag 759) - Lab Reports (See F-Tag 775) - Medical Records (See F-Tag 842) - Infection Control (See F-Tag 880) As a result, resident care was not provided in accordance to the facility policies and procedures, which could potentially result in physical and psychosocial harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75), had their right to refuse care honored, when certified nursing assistant (CNA) 1 continued to provide care after Resident 75 had refused care. This failure had the potential for Resident 75 to feel disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 247) was free from restraints when approximately seven to nine pillows were utilized in order to keep the resident from leaving the bed. This deficient practice had a potential negative psychosocial impact for Resident 247's wellbeing by being restrained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete baseline care plans for 3 of 21 sampled residents (Residents 71, 199 and 200). This failure had the potential for registered nurses (RN's) and licensed vocational nurses (LVN's) and certified nursing assistant (CNA's) with the inability to care for the sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure individualized and resident-specific written care plans were developed for three of 30 sampled residents (Residents 32, 50, and 75), reviewed for care planning, when: 1. Resident 75's personal preferences for incontinence (the inability to control urine or feces) care were not developed in a written care plan. 2. Resident 50's lack of teeth was not included in the development of a written care plan. 3. Resident 32's risk for choking was not developed in a written care plan. These failures had the potential to negatively effect the residents' health, safety, quality of life, and cause miscommunication among caregivers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatment was provided in accordance with the physician's order for one of 30 sampled residents (Resident 17). This failure had a potential for Resident 17's wound to develop infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer (skin injuries caused by prolonged pressure on the skin) preventative measure was implemented when a pressure relieving mattress was not programmed in accordance with the physician's order for one of 5 residents (Resident 32) reviewed for pressure ulcer/injury. This failure had the potential for Resident 32 to develop pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises for one of four residents (Resident 25) reviewed for position/mobility. This failure had a potential for Resident 25 to develop muscle weakness and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 37 and 32 ) reviewed for accidents, were free from the risk of accidents and hazards when: 1. Certified nursing assistant (CNA) 1 and CNA 7 unsafely transferred Resident 37 from the resident's bed to the wheelchair. 2. Resident 32 had a crumpled up surgical mask inside of his mouth. These failures had the potential for Resident 37 to sustain falls or other injuries, and for Resident 32 to choke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the peripherally inserted venous catheter (PIV/IV - needle inserted into a blood vessel used for hydration and/or medication) site with date, time, and initials of the licensed nurse (LN) for one of 30 sampled residents (Resident 199). This failure had the potential to increase Resident 199's risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent completion of hemodialysis (dialysis- a life support treatment that replaces many of the kidney's functions) assessments for 2 of 2 sampled dialysis residents (Resident 21 and 36). This failure had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care for Resident 21 and Resident 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the target behaviors were appropriate and side effects were monitored for the use of psychotropic (affecting mental activity) medications for two of 5 residents (Residents 36 and 3) reviewed for unnecessary medications. Failure to monitor appropriate target behaviors for Resident 36 had the potential to affect the ordering physician's ability to determine the effectiveness of the medication. In addition, Resident 3 experienced drowsiness that was not identified and reported to the resident's physician.

Inspectors wroteBased on observation, interview and record review, the faility failed to ensure that IV tubing was labeled apropriatly for two of 30 sampled residents [199 and 200].

Inspectors wroteBased on interview and record review the facility failed to have laboratory reports filed in the resident's clinical record for one of three residents (Resident #31). As a result, the nursing staff was unable to properly assess if Resident 31 had abnormal laboratory results that had the potential for Resident 31 not to receive competent medical interventions if needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate dental services as ordered for one resident (Resident 50). As a result, Resident 50 did not get her ordered dentures and was at risk for choking, poor nutrition, and potential loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 23) had his food allergies, dislikes, and preferences clearly identified. In addition, some nursing staff could not identify a dislike from a food allergy. This failure had the potential to cause harm if a food allergy was served to a resident by mistake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' refrigerator on Station 2 was maintained in a clean and sanitary condition. This failure had the potential to expose the residents' food to unclean conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents' (Resident 17) medical record was accurate, when a licensed nurse (LN) documented a wound treatment as done, when the treatment to the resident's wound was not performed. This failure had the potential to cause miscommunication of Resident 17's wound treatment to the other health care providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when hand hygiene was not performed between glove changes during a wound treatment observation on 1 of 30 sampled residents (Resident 398). This failure had the potential for an increase in facility-acquired infection and medical complications for Resident 398.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was adequate staff to provide the necessary care for six confidential residents (CR 1, CR 2, CR 3, CR 4, CR 5, and CR 6), and 8 of 28 residents reviewed for sufficient staffing (90, 105, 318, 321, 44, 103, 316, and 319). This failure had the potential for residents to experience physical and emotional harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the lunch menu for one of six residents reviewed for food (318). This failure had the potential for Resident 318's nutritional status to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respectful care for one of three residents (317) reviewed for dignity. This failure had the potential to negatively impact Resident 317's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an appropriate call light device was provided to one of 26 residents (9) reviewed for accommodation of needs. This failure resulted in Resident 9 being unable to call for assistance when Resident 9 required help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy during the delivery of care, for one (29) of 26 residents reviewed for privacy. This failure resulted in a lack of privacy when care was provided to Resident 29.

Inspectors wroteBased on interview and record review, the facility failed to accurately document a discharge status in the MDS (health status screening and assessment tool) for one of three residents (116) reviewed for MDS coding. This failure had the potential to result in miscommunication of the resident's discharge status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide fingernail trimming in a timely manner for two of two residents (6 and 20) reviewed for ADLs. This failure had the potential to cause skin tears and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and record the urinary output for one of four residents (70) reviewed for catheter care. This failure had the potential to cause Resident 70 to have a urinary output deficit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the lunchtime meal intake for two of six residents (3 and 5) reviewed for nutrition. This failure had the potential to cause the residents to become malnourished.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the administration of a pain medication was documented in the eMAR for one of four residents (79) reviewed for medication reconciliation. This failure had the potential for Resident 79 to receive too much or too little pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dietary staff member was unable to competently test the chemical concentration of the sanitizing solution. As a result, there was the potential for placing the residents at risk for food borne illnesses.