Vista View Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 21, 2021

  Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75) reviewed for abuse and neglect, was free from physical and verbal abuse and neglect when: 1. Certified nursing assistant (CNA) 1 handled Resident 75 in a rough manner during incontinence (an inability to control the release of urine or feces) care. Furthermore, CNA 1 did not stop providing care when Resident 75 requested for her to stop. 2. CNA 1 told Resident 75, No one likes you here. You complain too much, and called the resident a racist. 3. CNA 1 did not clean Resident 75 after an incontinence episode as per the resident's request. As a result of these failures, Resident 75 experienced physical pain and was in fear of CNA 1. […]

• No harm, potential for more than minimal, widespreadF865Jun 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. […]

• No harm, potential for more than minimal, widespreadF865Jun 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. […]

• No harm, potential for more than minimal, patternF755Jun 21, 2021

  Based on observation, interview, and record review, the facility failed to provide routine medications to four of four residents (Residents 7, 81, 39, and 75) in a timely manner according to the physician's orders (cross reference F 759). This deficient practice had the potential to not meet the medical needs of all residents. Findings: Resident 7 was readmitted to the facility on [DATE], and was her own responsible party (medical decision maker), per the facility's Admission Record. […]

• No harm, potential for more than minimal, patternF759Jun 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 20 percent. Six (6) medication errors were observed, a total of 30 opportunities, during the medication administration process for two (2) of three randomly observed residents (Residents 36 and 39). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 9/2/21 at 9:45 A.M., an observation of medication administration was conducted with licensed nurse (LN) 4. […]