Almond Vista Healthcare

In the surveyor’s words

From the most serious findings on record at Almond Vista Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 16, 2025

  Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury. These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. […]

• Actual harm, isolatedF689Dec 3, 2024

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate supervision to prevent accidents when Resident 1 was admitted on [DATE] from an acute care hospital with known history of difficulty swallowing, assessed need for strict aspiration precautions (safety measures to prevent patients from breathing in foreign objects, like food or liquids, into their lungs), Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) indicating moderate cognitive deficits (a stage of dementia where a person has significant difficulty with complex tasks and navigating new places) and need for assistance with meals and a care plan was not developed to address… […]

• Actual harm, isolatedF600Jan 25, 2024

  Based on interview and record review, the facility neglected to provide goods and services when they did not obtain and administer a medication ordered that was necessary to avoid physical harm and psychosocial distress to one of three sampled Residents (Resident 1) when Resident 1 was ordered an antiviral medication upon admission which was not acquired by the facility nor administered for seven days. This failure resulted in Resident 1 being neglected by staff and experienced psychosocial harm and anxiety which prompted Resident 1 to leave the facility against medical advice (AMA) for fear of physical harm due to the gap in the administration of his medication regimen and potential for risk of a worsening viral infection. […]

• Actual harm, isolatedF689Mar 17, 2023

  Based on observation, interview and record review, the facility failed to ensure residents' environment was free from accident hazards for one of two sampled residents (Resident 1) when nursing staff was aware of Resident 1's behavior of swinging a large 10-inch speaker call-light [the type of call light residents in the facility use] and did not replace the large 10-inch speaker call-light to prevent accidents. This failure resulted in an avoidable injury to Resident 1's both eyes on 3/9/22 from the swinging of the speaker call-light, causing swelling and bruising which worsened over several days. Findings: During a concurrent observation and interview, on 3/15/22, at 12:59 p.m., in Resident 1's room, Resident 1 was in bed and had a black discoloration on both of her eyes. […]

• Actual harm, isolatedF689Feb 28, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents, Resident 1 (R1), when R1 did not receive one-on-one supervision on 7/29/20 in accordance with the assessed need and care plan and the facility policy and procedure on smoking. These failures resulted in R1 being permitted to smoke outside unsupervised, falling from her wheelchair onto her right arm and shoulder; having to be transported to an acute care hospital (ACH) for evaluation with fracture to the right humerus (largest bone of the upper arm) and greater tuberosity (the prominent area of bone at the top of the humerus and is the attachment for the two large powerful rotator cuff muscle), treatment for pain and splint/cast (a device used to… […]