Vista Ridge Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Vista Ridge Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 9, 2021

  Based on observations, record reviews, and interviews, the facility failed to ensure one (#226) of four residents reviewed for pressure injuries out of 33 sample residents received care consistent with professional standards of practice. The facility failed to define and implement interventions that were consistent with resident needs, and to monitor and evaluate the effectiveness of interventions and re approach as necessary to prevent the development of pressure injuries for Resident #226. Resident #226 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident did not have pressure wounds at the time of admission. An interview with the resident's primary care physician revealed the resident had a form of [CONDITION(S)]. […]

• Actual harm, isolatedF686Dec 14, 2023

  Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#48 and #54) of four residents out of 33 sample residents. Resident #54 was admitted to the facility with a known risk of developing pressure wounds. The resident developed a blister on the right heel caused by poor-fitting shoes the wound started as a blister that worsened and required medical attention. […]

• Actual harm, isolatedF686Sep 1, 2022

  Based on observation, interviews and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#61) of two residents reviewed of 44 sample residents. The facility failed to provide the necessary equipment, interventions and care timely for a resident who was identified to be at risk for developing pressure ulcers due to the presence of a right femoral fracture and use of an immobilizing device. Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was hospitalized from 7/26/22 to 8/3/22 following a fall and subsequent fracture of her right femur. A skin assessment was completed upon Resident #61's readmission to the facility on [DATE]. […]

• Actual harm, isolatedF689Sep 1, 2022

  Based on interviews and record review the facility failed to ensure the environment remained free from accidents and hazards and that residents received adequate supervision and assistive devices to prevent accidents for two (#61 and #7) of three residents out of 44 sample residents. Resident #61 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], muscle weakness, lack of coordination, and abnormalities of gait and mobility. The resident required extensive, two person assistance for toileting and transfers. On 7/26/22, the resident fell in her bathroom during a transfer with one certified nurse aide (CNA) assisting. The resident was sent out to the hospital on 7/27/22 due to increased pain to her right lower extremity. […]

• No harm, potential for more than minimal, widespreadF725Dec 14, 2023

  Based on interviews and record reviews, the facility failed to provide and deploy sufficient nursing staffing during weekends to meet the needs of residents in keeping with their comprehensive care plans and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient nursing staff fiscal year (FY) Quarter 3 2023 (April 1-June 30) with excessively low weekend staffing to provide dignified and quality care, prevent falls and accidents, and prevent pressure ulcers. Cross-reference F686: failure to prevent pressure ulcer; and F689 failure to prevent falls and accidents. Findings include: I. Facility policy On 12/13/23 at 3:12 p.m., the facility's staffing policy was requested from the nursing home administrator (NHA). […]