Vista Center at the Ridge

In the surveyor’s words

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

• Actual harm, isolatedF684Jan 30, 2024

  Based on closed medical record review, hospital record review, review of facility policy and interview the facility failed to ensure effective and timely ongoing monitoring and assessments were completed for a non-pressure related skin impairment to Resident #132's right forearm. Actual Harm occurred on 01/02/24 at 1:14 P.M. when Registered Nurse (RN) #612 identified a previous open area to Resident #132's right forearm contained thick black necrotic eschar (dead tissue) and was significantly larger in size measuring 12 centimeters (cm) in length by ten cm width. […]

• Actual harm, isolatedF686Jan 30, 2024

  Based on observation, record review, facility policy review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #79 and Resident #124. Actual Harm occurred on 11/30/23 (six days after admission) when Resident #79, who was cognitively impaired and required total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have a Stage III (full thickness loss of skin where adipose (fat) was visible in the ulcer) pressure ulcer to her right buttock. The pressure ulcer was assessed to deteriorate to an unstageable pressure ulcer on 12/07/23. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based on observation, staff interview and facility policy review, the facility failed to ensure food was labeled and dated appropriately. This had the potential to affect 143 of 144 residents who received meals from the facility kitchen. The facility identified one resident (#50) who received no food by mouth. The facility census was 144. Findings include: Observations during of the main initial kitchen tour conducted on 02/03/25 between 8:27 A.M. and 9:10 A.M. with [NAME] #1238 revealed the following concerns: The main walk-in refrigerator contained one pork loin in a metal container that was undated and unlabeled. […]

• No harm, potential for more than minimal, widespreadF887Feb 6, 2025

  Based on review of personnel records and interview the facility failed to maintain documentation the COVID-19 vaccine was offered to the staff, and the staff were provided education regarding the benefits and risks associated with COVID-19 vaccine annually. This had the potential to affect all 144 residents in the facility. Findings include: A review of Certified Nursing Assistant (CNA) #1234's, CNA #1274's, CNA #1226's, CNA #1315's and Licensed Practical Nurse (LPN) #1231's personnel records revealed there was no documentation the facility had provided education and/or offered the information/consent regarding the COVID-19 vaccine. An interview with Infection Control Preventionist (ICP) #1240 on 02/06/25 at 10:50 A.M. […]

• No harm, potential for more than minimal, patternF584Sep 6, 2025

  Based on record review, observations, review of the housekeeping cleaning schedule, interviews and facility policy review, the facility failed to maintain a clean and sanity environment for residents. This affected six (Residents #1, #2, #3, #4, #5, and #11) of 21 residents residing on the 400 unit and had the potential to affect all residents residing in the facility. The facility census was 144. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 12/18/18. Diagnoses included schizophrenia and unspecified intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition. 2. Review of the medical record for Resident #2 revealed an admission date of 10/07/21. […]