Vista Knoll Specialized Care Facility

In the surveyor’s words

From the most serious findings on record at Vista Knoll Specialized Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 11, 2026

  Based on interview and record review the facility failed to ensure one (Resident 3) of three residents who required total assistance with activities of daily living (ADL bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) was free from injury when: 1.There was no documented evidence of fall preventive measures verbalized by facility staff, 2.The at risk for fall care plan was not person centered, 3.admission Record for Resident 3 had an inaccurate diagnosis listed. As a result of this deficient practice, Resident 3 got out of bed unassisted, fell and sustained a nasal fracture and was sent out to the hospital. […]

• No harm, potential for more than minimal, patternF584Aug 26, 2022

  Based on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for one out of 24 sampled residents (87), five unsampled residents (1, 38, 96, 309, 312), and two confidential group residents. This deficient practice had the potential for residents to feel uncomfortable. Findings: A review of Resident 87's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 38's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 96's Admission Record indicated the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF758Aug 26, 2022

  Based on interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) was free from unnecessary [CONDITION(S)] (is any medication that affects brain activities associated with mental processes and behavior.) medications as per the facility's policy & procedure. * The facility failed to attempt gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.) and no clinical contra-indication was documented. * In addition, the facility failed to implement any non-pharmacological interventions (interventions not involving a medication for mental illness). […]

• No harm, potential for more than minimal, patternF842Aug 26, 2022

  Based on observation, interview, and record review, the facility failed to ensure the clinical records of 14 residents (Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96) in rooms A through H were stored in a safe and secure manner when the residents' clinical records were stored on a rolling bookcase in the residential hallway. This deficient practice had the potential for Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, and 96's private health information to become lost, destroyed, or accessed by unauthorized persons. Findings: A review of Resident 311's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 151's Admission Record indicated the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF640Jun 11, 2026

  Based on observation, interview and record review the facility failed to timely complete the Minimum Data Set (MDS-a federally mandated clinical assessment tool) for one of three residents (Resident 3), reviewed for Resident Assessment, as required by Federal regulation S483.20(f)(3). This failure had the potential for a delay in care planning of Resident 3's ongoing clinical problems.Findings: Resident 3 was readmitted to the facility on [DATE] according to the facility's admission Record. A review of Resident 3's hospital history and physical, dated 4/28/26, prior to 5/1/26 admission to the facility, indicated a diagnosis of right femoral neck (flat bone connecting the ball of the hip bone to the thigh bone) fracture from a mechanical fall and dementia. […]