Vista Grande Rehabilitation and Healthcare Center

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

A complaint survey, prompted by #CO39666 was conducted on 4/9/25 to 4/10/25. One deficiciency was cited. Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#1) of three residents reviewed for pressure injuries out of five sample residents.Specifically, the facility failed to implement interventions to prevent the development of a pressure injury for Resident #1.Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com on 4/17/25, "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate ' at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin Loss. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. The Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin Loss. Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage3 pressure ul..

A survey prompted by #CO39593 was completed on 3/5/25 to 3/6/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents.Resident #2 admitted to the facility on 11/20/24 with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1' s electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1' s falls. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator.The policy identified the following steps that should be taken after the initial data was collected: "The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. "The DON shall ensure that the administrator receives a copy of the incident/accident form on each occurrence."The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities."II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 11/20/24. According to the March 2025 computerized physician' s orders (CPO), diagnoses included acute and chronic respiratory..

A survey prompted by Incident #39322 was conducted 3/5/25-3/6/25. Three deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents.Resident #2 admitted to the facility on 11/20/24 with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1' s electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1' s falls. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent par.. Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#1) of two residents out of three sample residents. Specifically, the facility failed to timely report an injury of unknown origin for Resident #1 to the State Agency. Findings include: A. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator."The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing services within 24 hours of the incident .. Based on record review and interviews, the facility failed to thoroughly investigate an allegation of abuse and neglect for one (#1) of one resident out of three sample residents. Specifically, the facility failed to complete a thorough investigation when Resident #1 sustained an injury of unknown origin. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, and vendors occurring on premises shall be investigated and reported to the administrator."The nurse supervisor/charge nurse and or the department director or supervisor shall promptly initiate a document investigation of the accident or incident."The policy identified the following data should be reported on a report of incident/accident form: "The date and the time the accident or incident took place; the nature of the injur..