Park Vista Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Park Vista Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF757Mar 10, 2021

  Based on medical record review, interviews with facility staff, Laboratory Supervisor #301, Nurse Practitioner (NP) #303, and Medical Director (MD) #302, review of laboratory (lab) testing results, review of facility policies, and Medscape.com guidelines, the facility failed to ensure Resident #45's critical high International Normalized Ratio (INR) (used to monitor therapeutic levels of blood clotting), and a low hemoglobin (part of the red blood cells that carries oxygen to all the cells in the body) were immediately reported to the resident' s primary physician. Resident #45 received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME] ([MEDICATION NAME]). […]

• Actual harm, isolatedF689Jan 16, 2026

  Based on observation, record review, review of hospital records, review of a facility investigation, review of an emergency medical service (EMS) run report, review of the time and date weather historical data, facility policy review, and interview, the facility failed to ensure adequate supervision and monitoring to prevent hospitalization for hypothermia for Resident #66. In addition, the facility failed to ensure fall interventions were in place for Resident #48. This affected two residents (#66 and #48) of three reviewed for accidents. The facility census was 94. […]

• Actual harm, isolatedF677Apr 17, 2024

  Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #87, who required staff assistance for activities of daily living (ADL) care, received adequate and timely incontinence care. Actual Harm occurred on 04/10/24 when Resident #87, who was totally dependent on staff for bed mobility and toileting went from 04/10/24 at approximately 6:00 A.M. to 11:52 A.M. (almost six hours) before being provided incontinence care. Resident #87 was observed to be saturated in urine resulting in a red, bleeding, open area to her right thigh that was approximately the size of a dime. Resident #87 revealed her skin was raw, hurt, and burned from the lack of timely incontinence care. […]

• Actual harm, isolatedF692Nov 2, 2022

  Based on interview, observation and record review, the facility failed to manage Resident #23's nutritional needs while accommodating the resident's allergies. This affected one of nine residents (#2, #18, #23, #24, #34, #6, #73, #35, and #53) identified with food allergies. Resident #23 experienced actual harm including emergent transfer to hospital and subsequent admission to intensive care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the at risk for allergic reaction plan of care initiated on 07/15/22 indicated Resident #23 had allergies to fish, nuts, shell fish, shrimp and tree nuts. […]

• Actual harm, isolatedF690Feb 15, 2022

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and services were provided, physician orders were followed, and care planned interventions were implemented for Resident #73 and #84's suprapubic catheters. Actual Harm occurred on 01/19/22 when Resident #84's suprapubic catheter did not drain urine properly, only had 50 cc (cubic centimeters) of urine output per day for three days from 01/16/22 through 01/19/22, resulting in pain and discomfort near the catheter site, and after being evaluated at the emergency department his catheter was found to be clogged with sediment. […]