Splendido at Rancho Vistoso

In the surveyor’s words

From the most serious findings on record at Splendido at Rancho Vistoso, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 10, 2024

  Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. The deficient practice could result in increased risk of injury to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. […]

• No harm, potential for more than minimal, patternF550Jul 24, 2026

  Based on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure that staff knocked prior to entering the rooms of 4 residents (#11, #3, #13 and #29). The deficient practice could impact the resident's level of privacy and their psychosocial well-being.Findings include:-Regarding Resident #29:Resident #29 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, essential hypertension, major depressive disorder-recurrent, anxiety disorder, type 2 Diabetes Mellitus, shortness of breath, atrial fibrillation, use of anticoagulants, unsteadiness on feet, and muscle weakness.The annual MDS (minimum data set) dated May 22, 2026 revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating that the… […]

• No harm, potential for more than minimal, patternF657Jul 24, 2026

  Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that comprehensive care plans were updated, care plan conferences were conducted, and care plans were revised to reflect residents' current needs for 3 of 3 sampled residents (#11, #17, and #33). The deficient practice had the potential to result in residents and/or their representatives not participating in the development and review of the plan of care, not understanding the resident's current care needs and goals, and staff providing care that was not based on an accurate, current, and individualized care plan. […]

• No harm, potential for more than minimal, patternF727Jul 24, 2026

  Based on staff interviews and review of facility documentation and policy, the facility failed to provide services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 38. The deficient practice could result in resident not provided with advanced care activities to meet their needs.Findings Include:The Facility Assessment with completion date of February 7, 2026 revealed an average daily census range of 28-35 for long-term care and 2-7 for short stay. Staffing plan included one FT (full-time) Director of Nursing (DON), 1-3 Licensed nurses providing direct care, and other nursing personnel with administrative duties that would include the lead nurse, minimum data set (MDS), assistant director of nursing (ADON), and Medical Records. […]

• No harm, potential for more than minimal, patternF761Jul 24, 2026

  Based on observations, clinical record reviews, staff interviews and facility documentation and policy review, the facility failed to ensure there were no expired items readily available for resident use; failed to ensure that that medications were not left at bedside during medication administration; and, failed to provide for safe and secure storage for medication for two residents (#29, #1). The deficient practice could result in placing residents at risk for medication errors, unauthorized access, and potential adverse health outcomes. […]