The Suites Rio Vista

In the surveyor’s words

From the most serious findings on record at The Suites Rio Vista, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580May 6, 2022

  Based on record review and interview, the following was identified: 1. A resident began to require oxygen (O2) use more frequently after arrival to the facility, and neither the resident's Power of Attorneys (POA's) or the residents primary physician was notified of use. 2. The resident required additional O2 therapy after a physical therapy session and also stated to the Physical Therapist (PT) that he did not feel himself. PT reported changes to nursing staff, but nursing staff did not notify resident POA's or residents primary physician. 3. The facility failed to notify appropriate and responsible parties of the residents change. These deficient practices resulted in Immediate Jeopardy being called on [DATE] at 5:32 pm. […]

• Actual harm, patternF689Aug 31, 2022

  Based on record review and interviews, the facility failed to prevent accidents by not implementing interventions to prevent falls for 1(R #77) of 1 (R #77) resident reviewed for multiple falls with injuries. This deficient practice likely caused resident to have multiple falls and also put resident at increased risk to have increased falls and sustaining further injuries. The findings are: A. Record review of R #77's face sheet revealed R #77 was admitted to facility on 12/18/21 with the following diagnosis: 1. Unspecified dementia without behavioral disturbances [a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.] 2. […]

• Actual harm, isolatedF689Feb 11, 2026

  Based on record review and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for 1 (R #88) of 1 (R #88) residents reviewed when staff left R #88's bed in the highest position, and R #88 fell from the bed. This deficient practice likely resulted in R #88 sustaining a right femur fracture (long bone that connects the hip to the knee) and spinal compression fractures (a break in a bone in your spine) which required hospitalization. Failure to ensure residents' beds are maintained in the appropriate position while occupied increases the likelihood of avoidable accidents, and places residents at risk for serious injury, significant harm, and potential death.The findings are: A. […]

• Actual harm, isolatedF600May 5, 2023

  Based on observation, record review, and interview, the facility failed to ensure that residents are free from abuse for 1 (R #1) of 2 (R #'s 1 and 2) residents reviewed for abuse by not implementing adequate corrective measures to prevent further abuse. This deficient practice likely resulted in R #1 experiencing severe mental anguish, anxiety and fear that she may be threatened and assaulted. The findings are: 41988 A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. METABOLIC ENCEPHALOPATHY [a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body]. 2. […]

• Actual harm, isolatedF686Aug 31, 2022

  Based on observation, record review and interview, the facility failed to ensure that 1 (R #48) of 1 (R #48) residents received care consistent with professional standards to treat and prevent pressure injuries by not ensuring R #48's pressure relieving devices were utilized as ordered (Prevelon boots, Air Mattress, off lifting Cushion while in bed). R #48 was admitted with a Stage 2 pressure injury (Partial thickness loss of skin which presents as a shallow open ulcer with red/pink wound bed without slough) to his right heel which progressed to a Stage 3 pressure [Open wound due to full thickness tissue loss. May include tunneling [creating a curved tunnel that makes the wound difficult to heal] injury (injury to the skin or tissue over a bony area). […]