Vista del Sol Care Center

In the surveyor’s words

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

• Actual harm, isolatedF692Mar 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents, (Resident 9), who was at risk for dehydration (lack of drinking sufficient fluids to meet the body's need) and malnutrition (food ingested [eaten]) does not provide enough nutrients or the right balance for optimal health), was offered sufficient food and did not experience unplanned severe weight (wt) loss (a body weight loss of greater than five [5] percent [% - unit of measure] in one month). The facility failed to: 1. Identify interventions related to Resident 9's poor food intake since admission to prevent progressive wt loss. 2. […]

• Actual harm, isolatedF695Mar 25, 2024

  Based on observation, interview, and record review, the facility failed to provide respiratory treatment and care for one of 16 sampled residents (Resident 13), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems) and history of pneumonia (a serious infection of one or both lungs in which the air sacs fill with pus and other liquid). The facility failed to: 1. Closely monitor Resident 13's respiratory condition, including response to treatment after being identified to have a change of condition (COC, a sudden clinically important deviation from a patient's baseline) when Resident 13 develop a cough on 3/20/2024. 2. […]

• Actual harm, isolatedF689May 17, 2023

  Based on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) identified as a high risk for fall from repeated falls by failing to: 1. Identify and evaluate hazard(s) and risk(s) related to the resident's specific risk and causes to prevent further falls and injuries. 2. Implement an intervention to address the nature of category of falling in which the resident fell . Resident 1 fell from the wheelchair in the three incidents of falls. 3. […]

• Actual harm, isolatedF689Apr 11, 2023

  Based on observation, interview, and record review, the facility failed to provide one to one supervision monitoring (a sitter), and to ensure that the care plan reflected the actual assessment for one of six sampled residents (Resident 1), who was identified as high risk for fall and have had multiple falls on 2/26/2023 and 3/8/2023. These deficient practices resulted in Resident 1 sustaining a right eyebrow laceration (a deep cut or tear in skin or flesh) on 2/26/2023, where Resident 1 was transferred to General Acute Care Hospital (GACH) for a physical examination, a Computed Tomography (CT, a medical imaging scan used to obtain detailed internal images of the body) of the brain and spine, and laceration repair. […]

• No harm, potential for more than minimal, widespreadF837May 17, 2023

  Based on interview and record review, the facility failed to ensure that the Administrator (Administrator 1) spent sufficient amount of time in the facility to perform his responsibilities as indicated the facility ' s policy titled Quality Assurance Performance Improvement Plan and the facility ' s Job Description for an Administrator as evidenced by: 1. 8 of 8 sampled facility staff Licensed Vocational Nurses (LVNs 1 and 2), Certified Nursing Assistants (CNAs 1, 2 and 3), the Physical Therapy Assistant (PTA), Director of Nursing (DON), and Registered Nurse 1 (RN 1) indicated it had been a while (from 1 to 5 months) since they last saw Administrator 1 in the facility. 2. […]