Royal Vista Care Center

In the surveyor’s words

From the most serious findings on record at Royal Vista Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 29, 2025

  Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as a high risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the Director of Activities (DOA) wheeled Resident 1 outside of the activity room to take care of other residents and left Resident 1 unattended while sitting in a wheelchair (WC) at the hallway (outside the activity room). This deficient practice resulted in Resident 1 fell in the hallway outside the activity room on 1/18/2025 around 11:13 AM. […]

• No harm, potential for more than minimal, widespreadF851Dec 8, 2023

  Based on interview and record review, the facility failed to ensure the Payroll Based Journal (PBJ, a system for healthcare facilities to submit staffing information. This system allows staffing information to be collected on a regular and more frequent basis than previously collected) report was completed. This deficient practice had the potential for the facility to not be adequately staffed and/or have the necessary staff to provide care to meet the needs of all the residents in the facility. Findings: A review of Centers for Medicare & Medicaid Services (CMS, the federal agency that provides health coverage) PBJ Staffing Data Report, dated 11/30/23, indicated facility did not submit staffing data for the fiscal quarter four (7/1/2022 to 9/30/2022). […]

• No harm, potential for more than minimal, widespreadF727Jun 21, 2022

  Based on observation, interview, and a review of the facility's job posting for the Director of Nurses (DON) position, the facility failed to designate a registered nurse to serve as full-time DON for 70 of 70 residents. This deficient practice left the facility without oversight for the nursing care provided to all 70 residents. Findings: During an interview on 06/21/2022 at 2:10 PM, the facility Administrator stated the facility did not have a DON. The Administrator stated the facility had an Assistant DON (ADON) but was assigned residents to care for. The Administrator confirmed the facility had not had a DON since April 2022. The Administrator stated advertisements were placed on the facility ' s website, but no one wanted the position after the interview process was completed. […]

• No harm, potential for more than minimal, patternF880Jul 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for three (3) of three sampled residents (Residents 1, 2 and 3) were followed in accordance with the facility's policy and procedure when:1. The facility staff failed to disinfect the shower chair used by Resident 1 before placing the shower chair back in the shower room for the next resident's use. 2. […]

• No harm, potential for more than minimal, patternF880Apr 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of three (3) sampled residents (Residents 1 and 3) with suspected (believed to have due to signs and symptoms and/ or exposure to confirmed) and confirmed (a doctor had officially identified) cases of scabies (is a highly contagious skin infestation caused by tiny, burrowing mites) in accordance with the facility's policy and procedure by failing to:1. […]