Azria Health Rose Vista

In the surveyor’s words

From the most serious findings on record at Azria Health Rose Vista, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 20, 2025

  Based on observation, provider interview, staff interviews, record review and policy review, the facility failed to provide timely and adequate skin care to prevent worsening of pressure ulcers for 2 of 3 residents reviewed. Resident #6 developed a pressure injury on her heel and staff failed to call the doctor when there was a change in the wound. Resident #71 was admitted to the facility with an identified Moisture Associated Skin (MASD), and staff failed to get a doctor's order for treatments. The facility reported a census of 69 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, patternF688Nov 20, 2025

  Based on facility document review, staff interviews and clinical record review the facility failed to establish and implement a restorative nursing program to help prevent residents from decline for residents discharged from Physical Therapy/Occupational Therapy (PT/OT) services. The facility reported a census of 69 residents.Findings include: According to the Beneficiary Notice-Residents discharged within the Last Six Months, the facility had 25 resident that were discharged from a Medicare covered Part A stay and remained in the facility. The Minimum Data Set (MDS) dated [DATE], showed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8 (severe cognitive deficit.) He required partial assistance with hygiene, dressing, sit to stand and transfers. […]

• No harm, potential for more than minimal, patternF725Nov 20, 2025

  Based on Electronic Health Record (EHR) review, document review, resident interview, staff interview and policy review, the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #8, #12, #20 and #38). The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 11/17/25 at 3:48 PM Resident #12 stated the facility had added several residents to the census recently and the facility could use more staff. […]

• No harm, potential for more than minimal, patternF803Nov 20, 2025

  Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 4 of 4 residents with a pureed diet (Resident #6, #13, #26, and #52) reviewed and also all the residents that ate the lunch meal on 11/19/25. The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia oropharyngeal phase. Review of Resident #6's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 10/22/25.2. […]

• No harm, potential for more than minimal, patternF803Nov 7, 2024

  Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portion of fried rice for 13 of 15 residents who received carbohydrate controlled or consistent carbohydrate diets. The facility reported a census of 49 residents. Findings include: On 11/05/24 at 11:57 AM, Staff A, cook, identified the following lunch menu items and corresponding serving size scoop size: a) Sweet & Sour chicken - 6-ounce (oz) scoop b) Oriental vegetables - 4 oz scoop c) Fried rice - 4 oz scoop A review of the Diet Type Report indicated 15 residents were ordered carbohydrate controlled/consistent carbohydrate diets. […]