College Vista Post-Acute

In the surveyor’s words

From the most serious findings on record at College Vista Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 3, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from accident smoking hazards by failing to: 1. Supervise and monitor Resident 1, who was non-compliant with the facility's smoking policy, titled Resident Smoking, when the resident went to the facility's outdoor patio to smoke a cigarette while on oxygen. 2. Implement Resident 1's care plan interventions of being non-compliant with the facility's smoking schedule and policy that indicates facility staff would supervise Resident 1 while smoking. 3. Ensure the facility nursing staff maintained Resident 1's smoking materials, in accordance with the facility's policy and procedures (P&P) titled, Resident Smoking. 4. […]

• Immediate jeopardy, isolatedF678May 6, 2024

  Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) was immediately provided CPR (cardiopulmonary resuscitation a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse] consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) prior to the arrival of emergency medical personnel in accordance with the standard of practice and the facility's policy and procedure titled Medical Emergency Response and Cardiopulmonary Resuscitation (CPR) by failing to: 1. […]

• Immediate jeopardy, isolatedF695May 6, 2024

  Based on interview and record review, the facility failed to assess, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia (condition in which tissues of the body are starved of oxygen), pneumonia (lung inflammation) and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and who was receiving continuous oxygen therapy by failing to: 1. Monitor and conduct respiratory assessment for complications associated with the use of oxygen and notify the primary physician (Physician 1). On [DATE] at 5:30 AM, Resident 41 verbalized not feeling well and asked the Licensed Vocational Nurse (LVN) 1 for her oxygen tank to be replaced because the resident, felt it was empty. […]

• Actual harm, patternF604Apr 29, 2021

  Based on observation, interview and record review, the facility failed to ensure the residents were free from physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) for one of three sampled residents (Resident 1). Certified Nursing Assistants (CNA) 2 and 3 tied Resident 1 with a cloth gown and/or a bed sheet to the waist and around the wheelchair to prevent Resident 1's freedom of movement when agitated and prevent a fall for about one year (exact date unknown) since CNA 1 and 3 first reported (7/29/20) the improper us of restraint on to the facility administrator. This deficient practice resulted in Resident 1's rights being violated, abused, and held against her will. […]

• Actual harm, isolatedF693Sep 17, 2021

  Based on observation, interviews, and record review, the facility failed to ensure a resident receiving enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum [first part of small intestine], or jejunum [middle part of the small intestine]) received appropriate care and services, according to current standards of practice in maintaining and verifying tube placement to prevent tube feeding complications, to the extent possible, for two of two sampled residents (Resident 1 and 2) including: 1. […]