Vista Manor Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Vista Manor Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF552Apr 18, 2026

  Based on observation, interview, and record review, the facility failed to coordinate, communicate, and document the change in diabetic treatment plan for a chronically ill resident who required a surrogate for decision making, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. Resident #1 and her representative were not informed of the risks associated with not receiving diabetic care and were not given the choice to make an informed decision on the treatment plan. […]

• Immediate jeopardy, isolatedF600Apr 18, 2026

  Based on observation, interview, and record review, the facility's Interdisciplinary Team (IDT) failed to protect the resident's right to be free from neglect by failing to identify the need for a diabetic treatment plan for a type II diabetic resident with a history of uncontrolled diabetes, chronic kidney disease, and recurrent urinary tract infections which placed her at a high risk for decline, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. […]

• Immediate jeopardy, isolatedF684Apr 18, 2026

  Based on observation, interview, and record review, the facility failed to coordinate and communicate effectively among the interdisciplinary team to ensure diabetic residents received continuity of care in accordance with professional standards of practice, the care plan, and resident choice to attain or maintain their highest practicable physical, mental and psychosocial wellbeing, (#1). This failure in care coordination resulted in a lack of proper blood glucose monitoring and treatment for 48 days, during which resident #1 developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. The resident required emergency 911 transfer to the hospital and admission to the Intensive Care Unit (ICU), for 3 days. […]

• Immediate jeopardy, isolatedF867Apr 18, 2026

  Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified and addressed a systemic process failure related to coordination, communication, and continuity of care for a resident requiring diabetes management. Following a resident's hospitalization for complications related to not receiving diabetic treatments for 48 days, the facility failed to immediately identify the factors that contributed to the resident's decline. […]

• Immediate jeopardy, isolatedF689Aug 13, 2022

  Based on observation, interview and record review, the facility failed to supervise a physically and cognitively impaired vulnerable resident while he was left outside in the facility courtyard in the sun and extreme heat for 1 of 7 residents reviewed for supervision of a total sample of 13 residents, (#1). The resident remained in the courtyard for one and half hours and suffered heat exhaustion, dehydration, life threatening [CONDITION(S)] and hospitalization . On 8/01/22 at approximately 11:30 AM, resident #1 was assisted to the outdoor courtyard by the Physical Therapy (PT) student. Neither the PT student nor the therapist observed any staff in or near the courtyard and did not inform resident #1's nurse or Certified Nursing Assistant (CNA) that the resident was in the courtyard. […]