Vista Hills Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF908May 23, 2022

  Based on observation, interview, and record review revealed the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 6 of 6 exit door alarms on resident hall s, 1 of 1 gate alarm in enclosed area by A Hall which resulted in an elopement of 1 of 7 (Resident #1) residents identified at risk of elopement. The facility failed to maintain battery operated door alarms on exit doors in resident halls A, B, C, D, E, and F according to manufacturer's specifications, to prevent accidents, for Resident #1 who had a history of wandering and was at risk for elopement. […]

• Immediate jeopardy, isolatedF689Oct 31, 2025

  Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for repositioning.The facility failed to ensure adequate supervision and safe handling techniques were provided during routine repositioning to prevent injury for Resident #1 who sustained a spiral fracture of the distal right femur while being repositioned in bed by a CNA C.This failure could place residents at risk for injuries.The noncompliance was identified as PNC-IJ. […]

• Immediate jeopardy, isolatedF689May 23, 2022

  Based on observation , interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 7 residents reviewed for wandering. The facility failed to provide adequate supervision for Resident #1 who had a history of wandering and at risk of elopment. Resident #1 exited the facility on 05/15/22 at 11:25 PM, through an exit on A Hall and then exited the gated area at the side of facility that had a magnetic lock and keypad, into the front parking lot by a high traffic street. Resident #1 sustained a large laceration to forehead that required 20 sutures and dense fracture of C1 and C2 (fractures of neck region of spinal column). Resident #1 fell down and sustained injuries. […]

• No harm, potential for more than minimal, widespreadF727Apr 30, 2026

  Based on interviews, observation, and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 03/04/2026 through 03/17/2026, and 04/01/2026 to 04/19/2026. This failure could place all residents at risk of not receiving necessary care and services.Findings included:Record review of DON E's timesheet, with no date, revealed his last day working was 03/03/2026. Record review of Job Offer letter dated 03/19/2026, noted a job offer was extended to DON F for the role of the Nursing Facility's DON with start date 03/18/2026. […]

• No harm, potential for more than minimal, patternF695Feb 11, 2026

  Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #33, Resident #43 and Resident #68) of 16 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident # 33, and Resident # 43 while the oxygen was in use, concentrators was observed with air filters with dust, and lint collected on them on 02/09/2026.The facility failed to ensure Resident #68's dirty nasal cannula was replaced when it was observed on the floor on 02/09/26 and CNA F used a wipe to clean the nasal cannula.This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate… […]