Vista Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF759Jan 30, 2025

  Based on observation, interviews, and record review, the facility had a medication error rate of 13.79% when four medication errors occurred out of 29 opportunities during the medication administration observation for four out of nine residents (Residents 3, 8, 10, and 37). Resident 37 did not receive one medication as scheduled; Resident 8 received insulin with incorrect priming; and Residents 3 and 10 did not receive one medication as prescribed. The failures resulted in the residents not receiving the medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar or blood pressure). Findings: 1. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Kitchen wall had an opening in the wall around the drain; 4. Kitchen backsplash, where dishes were cleaned, had food and black substance buildup; 5. A kitchen cleaning schedule was not maintained according to facility policy; 6. Frozen meat did not have date received, date placed in freezer, use by date, and expiration date; 7. Produce and food were not labeled with use by date and were not rotated with FIFO, First in-First out per facility policy; 8. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2025

  Based on observation, interview, and record review, the facility failed to observe proper infection control practices when: 1. A nursing staff failed to perform hand hygiene after touching potentially contaminated surfaces during the medication administration; 2. A nursing staff touched and opened two medication capsules with bare hands; 3. A nursing staff failed to observe the enhanced barrier precautions (EBP) as per facility policy and procedures (P&P) for two residents (Residents 37 and 61) during the medication administration; These failures had the potential for Residents 37, 54 and 61 to be placed at risk for infections. Findings: 1. […]

• No harm, potential for more than minimal, patternF759Sep 14, 2023

  Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health. Findings: 1. […]

• No harm, potential for more than minimal, patternF689Apr 29, 2021

  Based on observation, interview, and record review, the facility failed to keep two of three treatment carts (a portable cart containing supplies needed for wound care) locked when not in the view of a licensed nurse. This failure had the potential to result in injury to residents, staff, or visitors from unauthorized use of injection needles, scissors, and suture supplies (needles and surgical thread used to sew wounds closed). Findings: During an observation on 4/26/21 at 11 a.m., at nursing station 3, on the ground floor of the facility, was an unlocked, unsupervised treatment cart. The second drawer of the cart was unlocked and contained surgical scissors, injection needles, and suture materials. There was no licensed nurse present at nursing station 3, or on the ground floor. […]