Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Grande Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple risk factors for pressure injuries did not consistently receive ordered interventions such as a pressure redistribution mattress and heel protectors, leading to the development of a new heel wound. Documentation and assessment of the wound were incomplete, and staff interviews confirmed lapses in both the implementation of preventive measures and ongoing evaluation of the resident's condition.
A resident with severe cognitive impairments and a history of falls experienced multiple incidents due to inadequate supervision and delayed interventions. Despite known risk factors, the facility failed to update care plans promptly and did not secure the environment, leading to a serious injury when the resident self-transferred in an unsecured shower room.
A resident with severe cognitive impairments was admitted to the hospital with bilateral hip fractures and a hematoma, but the LTC facility failed to report the injury of unknown origin to the State Agency within the required timeframe. The incident occurred, but the facility did not report it until 24 days later, contrary to their policy. The NHA did not save investigation notes, and the DON acknowledged the reporting failure.
A resident with severe cognitive impairments sustained bilateral hip fractures and a hematoma, but the facility failed to conduct a thorough investigation as required by their policy. The investigation lacked staff and resident interviews, and inconsistencies were found in staff accounts. The facility did not document or investigate a bruise of unknown origin reported by the hospital, leading to a deficiency in addressing the resident's injuries.
The facility failed to ensure a safe environment for two residents, leading to multiple falls for one resident due to inconsistent implementation and follow-up of fall interventions. Despite having a care plan, the facility did not consistently follow it, resulting in repeated falls and a major injury requiring hospitalization.
The facility failed to ensure that three residents had the right to formulate an advance directive. Specifically, the facility did not provide written advance directive forms or discussions to the residents, did not re-evaluate their decision-making capacity periodically, and did not re-evaluate if their advance directives were still in line with their wishes.
The facility failed to test residents with upper respiratory infections for COVID-19 and did not vaccinate residents who had consented to receive the COVID-19 vaccine. This lapse in infection control practices was acknowledged by the DON and the CC during interviews.
The facility failed to ensure CNAs received at least 12 hours of annual in-service training, including dementia management and abuse prevention. A review of training records showed that none of the five randomly selected CNAs met the required training hours. Interviews revealed a lack of awareness and proper tracking of training hours among the staff.
The facility failed to ensure care for residents was provided in a manner that maintained or enhanced their dignity and respect. Staff did not acknowledge or respond to a resident when she spoke, failed to treat another resident with respect during meals, and yelled at or moved a third resident hastily. Multiple residents reported being yelled at during meals, and observations confirmed these actions, which were not in line with the facility's dignity policy.
The facility failed to obtain informed consents for the use of psychotropic medications for two residents. One resident was prescribed Trazodone without documented consent, and another was prescribed Seroquel without documented consent until it was obtained during the survey. The facility's policy requires consents prior to administration, but documentation was incomplete.
The facility failed to ensure proper management of personal funds accounts for four residents. Specifically, there were no signed written authorizations for one resident, and personal funds withdrawal sheets lacked signatures for four residents. The facility's policy required written authorization and signatures on receipts, but these were not obtained, leading to unauthorized management and withdrawals of residents' funds.
The facility failed to notify two Medicaid-funded residents or their legal representatives when their personal funds accounts approached the Medicaid eligibility resource limit. One resident's account exceeded the limit, and another's was close to it, with no documentation of required notifications.
The facility failed to protect a resident from potential sexual abuse by another resident. The incident, captured on video, lasted over ten minutes before staff intervened. The resident with a history of inappropriate behaviors was placed on 15-minute checks, but the facility did not implement sufficient preventive measures or document staff training and interviews.
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not evaluate a resident for the use of a restraint, obtain a signed consent, or secure a physician's order for the restraint. Additionally, the facility did not complete quarterly safety risk assessments, document less restrictive measures attempted, or conduct trial periods without the restraints for two residents.
The facility failed to provide adequate restorative and occupational therapy services to two residents with limited range of motion, leading to deficiencies in their care. Both residents did not receive the required therapy sessions as per their care plans, and staff interviews confirmed inconsistencies and challenges in service delivery.
A resident with severe cognitive impairment and multiple diagnoses, including COPD and hypoxemia, was frequently observed without his oxygen cannula in place. Staff did not consistently remind or assist the resident to wear his oxygen, and the care plan lacked clear directives on oxygen use. The DON and NHA acknowledged that the resident's oxygen needs and refusals had not been adequately addressed.
The facility failed to ensure proper storage and monitoring of medications, including expired medications in storage carts and incomplete temperature logs for refrigerated medications. Staff interviews confirmed these deficiencies and highlighted a recent process change that contributed to missed documentation.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure injuries received the necessary treatment and services to prevent the development of a new pressure ulcer. Despite having physician orders in place for a pressure redistribution mattress and heel protectors, these interventions were not consistently implemented or documented. The resident, who had multiple risk factors including dementia, diabetes, muscle wasting, and was dependent on staff for activities of daily living, was identified as being at risk for pressure ulcers and had a history of unhealed pressure injuries. Documentation revealed that the resident did not have a pressure redistribution mattress in use as ordered, and heel protectors were not implemented until after a new right heel wound was identified. There was a gap in documentation and implementation of these interventions, as the medication and treatment administration records did not show use of the mattress or heel protectors prior to the development of the wound. The wound was first noted as a non-blanchable area on the right heel, and subsequent wound evaluations did not consistently involve assessment by a physician, nurse practitioner, or wound care specialist, nor did they identify the source of pressure or factors contributing to improvement. Staff interviews confirmed that the resident's risk for pressure injuries increased as her condition declined, yet interventions were not adjusted accordingly. The facility's wound nurse acknowledged that the root cause of the pressure injury was not adequately identified and that the resident's shoes and leg rests may have contributed to the development of the heel wound. The facility also failed to ensure ongoing and thorough assessment of the wound, as the condition of the right heel was not evaluated after a certain point, and the nurse practitioner did not assess the wound until after the resident returned from a hospital stay.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and timely interventions to prevent accidents for a resident with a history of falls. The resident, who was admitted with severe cognitive impairments and required substantial assistance for mobility, experienced multiple falls over a period of several months. Despite the resident's known risk factors, the facility did not implement timely and effective interventions after each fall, contributing to repeated incidents. The resident sustained falls on several occasions, including an unwitnessed fall shortly after admission, where poor lighting and confusion were identified as factors. The facility did not update the resident's care plan with new interventions until weeks after the initial fall. Subsequent falls were either unwitnessed or witnessed by staff, yet the recommended interventions, such as placing the resident in a recliner or implementing a restorative program, were not promptly executed. This lack of timely action and failure to adhere to care plan recommendations contributed to the resident's continued risk of falls. The most severe incident occurred when the resident attempted to self-transfer in a shower room, resulting in a hip fracture. The shower room door was improperly left open, allowing the resident to enter unsupervised. The facility's failure to secure the environment and provide adequate supervision directly led to this serious injury. The incident highlights the facility's deficiencies in maintaining a safe environment and ensuring that staff follow through with care plan interventions to prevent accidents.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency in a timely manner. The resident, who was over 65 years old and had multiple medical conditions including severe cognitive impairments, was admitted to the hospital with bilateral hip fractures and a hematoma on her left thigh. The incident occurred on December 29, 2024, but was not reported to the State Agency until January 23, 2025, which was 24 days after the reporting requirements. The facility's policy required that all accidents or incidents involving residents be reported to the administrator and the appropriate agencies within 24 hours. However, the facility did not adhere to this policy. The nursing home administrator (NHA) initiated an investigation by reviewing hallway video and interviewing staff but did not save the interview notes, and the video was only saved for two weeks. The NHA reported the injury late because she did not know it was reportable. Interviews with staff revealed that the resident was fine the evening before the incident and had no reports of pain. However, when staff attempted to get her up the next day, she cried out in pain and was unable to stand. The resident was sent to the hospital, where she was diagnosed with fractures to both hips. The director of nursing (DON) acknowledged that unexplained injuries should have been reported within 24 hours, but this was not done in this case.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and neglect concerning a resident who sustained an injury of unknown origin. The facility's policy required a comprehensive investigation of all accidents or incidents, including documentation of the circumstances, witness accounts, and any corrective actions taken. However, the investigation into the resident's injuries did not include interviews with staff or residents after the incident, and the facility did not document or investigate a bruise of unknown origin reported by the hospital. The resident, who had severe cognitive impairments and required assistance with activities of daily living, was found to have bilateral hip fractures and a hematoma on her thigh after being sent to the hospital. The facility's records did not indicate any falls or incidents that could have caused these injuries. Staff interviews revealed inconsistencies in the accounts of the resident's condition and care, and the facility did not conduct a fall investigation or a bruise of unknown origin investigation, as required by their policy. The facility's failure to conduct a thorough investigation and document findings led to a deficiency in addressing the resident's injuries. The NHA and DON did not save interview notes or video evidence, and there was a lack of clarity regarding the resident's condition and the events leading to her injuries. The facility's inaction and incomplete investigation did not comply with their policy and procedures for handling incidents and accidents.
Failure to Implement and Follow Fall Interventions
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accidents/hazards as possible to prevent falls for two residents. Resident #3, who had a history of falling, experienced multiple falls due to the facility's failure to implement and follow appropriate fall interventions. Despite having a care plan that included wearing non-skid socks and a scheduled toileting program, these interventions were not consistently followed. Additionally, after each fall, the facility did not implement new fall interventions in a timely manner, leading to repeated falls and eventually a major injury requiring hospitalization for Resident #3. Resident #3's care plan was not adequately updated or followed. For instance, after a fall on 4/16/23, no new interventions were added until 6/16/23, and even then, the toileting schedule was not specified. Between 7/1/23 and 1/19/24, Resident #3 sustained six more falls, many of which occurred while attempting to go to the bathroom. The facility failed to ensure staff followed the toileting schedule and other care-planned interventions, such as wearing non-skid socks. Additionally, the facility did not address the resident's low oxygen levels, which were identified as a potential factor in the falls. The facility's documentation and investigation of falls were inadequate. For example, the fall occurrence evaluations often lacked details such as the type of footwear the resident was wearing, whether the resident was using oxygen, and when the resident was last toileted. The facility also failed to conduct thorough investigations and implement appropriate new interventions after each fall. This lack of proper documentation and follow-up contributed to Resident #3's repeated falls and eventual major injury. The facility's failure to consistently identify, implement, review, and update fall care plans with effective interventions also affected Resident #58, who experienced similar issues with fall prevention.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that three residents had the right to formulate an advance directive. Specifically, the facility did not provide written advance directive forms or discussions to the residents, did not re-evaluate their decision-making capacity periodically, and did not re-evaluate if their advance directives were still in line with their wishes. This deficiency was identified for three of the five residents reviewed for advance directives out of a sample of 41 residents. Resident #36, who was over the age of 65 and had diagnoses including cerebral palsy, osteoarthritis, and generalized muscle weakness, was moderately cognitively impaired. Despite being unable to recall what an advance directive was or if he had one, there was no documentation in his electronic medical record (EMR) indicating an advance directive discussion had been held. Similarly, Resident #37, who had dementia and other cognitive impairments, had multiple progress notes indicating the facility contacted his power of attorney (POA) for consents and appointments, but there was no documentation of an advance directive discussion. Resident #57, who was cognitively intact with a BIMS score of 13 out of 15, had a MOST form signed by a family member identified as the medical durable power of attorney (MDPOA). However, there was no MDPOA form documented in the EMR, nor was there any documentation indicating an advance directive discussion had been held. Interviews with the nursing home administrator (NHA), social services director (SSD), and director of nursing (DON) confirmed that there were no advance directives on file for these residents and that discussions regarding advance directives were not documented or re-offered periodically.
Failure to Test and Vaccinate Residents for COVID-19
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility did not ensure that residents presenting signs and symptoms of an upper respiratory infection were tested for COVID-19. Residents #22, #24, #16, #29, #47, #53, and #58 were identified with upper respiratory infections but were not tested for COVID-19, despite exhibiting symptoms that could potentially indicate the virus. The facility's surveillance mapping and electronic medical records did not document COVID-19 testing for these residents, and the DON confirmed that testing was not conducted unless a staff member reported positive COVID-19 or if local facilities had cases of a COVID-19 outbreak and the physician recommended testing. Additionally, the facility failed to ensure that residents who had consented to receive the COVID-19 vaccination were actually vaccinated. Residents #58, #164, and #165 had consented to receive the COVID-19 vaccine, but the facility did not administer the vaccine to them. Resident #58's responsible party consented for the vaccination on 3/19/24, but the resident was not vaccinated due to the family's initial decision to wait, and the facility did not follow up. Similarly, Resident #164 and Resident #165 had consented for the vaccination on 4/19/24 and 4/11/24, respectively, but were not provided the vaccine since their admission. The DON and the CC acknowledged the deficiencies during interviews. The DON stated that residents with upper respiratory infections were not placed on droplet precautions because there were no recommendations from the providers, and she did not follow up to ask if precautions were needed. The CC emphasized that the facility should test every resident with signs and symptoms of a respiratory infection to rule out COVID-19 and follow CDC recommendations for offering COVID-19 vaccinations to all residents. The facility's failure to test symptomatic residents for COVID-19 and to vaccinate consenting residents represents a significant lapse in infection control practices.
Failure to Ensure CNAs Received Required Annual Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received at least 12 hours of annual in-service training, including mandatory dementia management and resident abuse prevention training. A review of training records for five randomly selected CNAs revealed that none of them had completed the required 12 hours of training. Specifically, CNA #2 had only six hours of training with no record of abuse, neglect, or exploitation training; CNA #4 had six hours of training with no dementia management or abuse prevention training; CNA #5 had eight hours of training; CNA #6 had ten hours of training with no dementia management training; and CNA-Med #1 had nine hours of training with no dementia management training. Interviews with the nursing home administrator (NHA), business office manager (BOM), director of nursing (DON), and corporate consultant (CC) revealed a lack of awareness and proper tracking of the required training hours. The BOM admitted to not knowing the necessity of tracking training hours, while the DON was unaware of the 12-hour training requirement. The NHA acknowledged the difficulty in ensuring staff completed the training despite offering paid training sessions and flexible scheduling. The facility planned to implement a computerized training system within six months to improve tracking and consistency, but no immediate corrective actions were in place at the time of the survey.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure care for residents was provided in a manner that maintained or enhanced their dignity and respect. Specifically, staff did not acknowledge or respond to Resident #1 when she spoke to them, failed to treat Resident #23 with respect and dignity during meals, and yelled at or moved Resident #38 hastily when he got stuck on another resident's chair in the dining room. These actions were observed multiple times, indicating a pattern of behavior that did not align with the facility's dignity policy. Resident #1, who had severe cognitive impairments and communication difficulties, was repeatedly ignored by staff when she attempted to communicate. On several occasions, staff members did not respond to her expressions of gratitude or requests for assistance. Additionally, Resident #1 was observed eating food off the floor while waiting for a second plate of food, and no staff attempted to redirect her. The facility's policy and Resident #1's care plans emphasized the importance of allowing time for communication and providing support, but these were not followed. During a group interview, multiple residents reported that staff yelled at them during meals, particularly if they fell asleep or were hard of hearing. Resident #50, a survivor of domestic violence, stated that the yelling triggered her PTSD and made her feel unsafe. Observations confirmed that staff, including RA #1, yelled at residents to wake up and eat their food, and moved Resident #38's wheelchair without his consent. These actions were not in line with the facility's policy of treating residents with dignity and respect.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained for the use of psychotropic medications for two residents. Specifically, the facility did not obtain consents that included the risks associated with taking Trazodone for Resident #15 and Seroquel for Resident #20. Resident #15, who was cognitively intact and had diagnoses including chronic kidney disease, dementia, and insomnia, was prescribed Trazodone without documented consent. Similarly, Resident #20, who was moderately cognitively impaired with diagnoses including Parkinson's disease, dementia, and anxiety disorder, was prescribed Seroquel without documented consent until it was obtained during the survey. The facility's Antipsychotic Medication Use policy requires that consents be obtained prior to the administration of psychotropic medications. However, the electronic medical records and paper documentation for both residents failed to include the necessary consents. Interviews with the Director of Nursing, Corporate Consultant, and Nursing Home Administrator confirmed that consents were not obtained for these medications. The Nursing Home Administrator attributed the incomplete documentation to the newness of the Social Services Director in her role, indicating a need for improved documentation practices for psychotropic medications.
Failure to Properly Manage Residents' Personal Funds Accounts
Penalty
Summary
The facility failed to ensure that personal funds accounts were managed adequately for four residents. Specifically, the facility did not have signed written authorizations to manage the personal funds account for one resident and did not have personal funds withdrawal sheets signed to ensure the residents' permission was obtained for withdrawals from their personal needs accounts for four residents. The facility's policy required written authorization from the resident or authorized person before holding any funds and signatures or thumbprints on every receipt or record of the transaction. However, the facility did not comply with this policy, leading to unauthorized management and withdrawals of residents' personal funds. The business office manager (BOM) provided written authorizations for one resident, but these were signed by the previous BOM and not the resident or the resident's legal representative. Additionally, the personal funds withdrawal sheets for four residents showed multiple withdrawals without signed authorization from the residents or two staff members. The nursing home administrator (NHA) and the BOM were unaware of the requirement for signatures on the withdrawal forms and admitted that the facility did not have valid legal supporting documentation of their authority to manage the residents' funds. This lack of compliance with the facility's policy and federal regulations resulted in the mishandling of residents' personal funds accounts.
Failure to Notify Residents of Personal Funds Account Balances
Penalty
Summary
The facility failed to manage the personal funds accounts of two Medicaid-funded residents accurately. Specifically, the facility did not notify Resident #2 and Resident #7 or their legal representatives when their personal funds accounts reached $200 less than the eligibility resource limit for Medicaid. Resident #2 had a balance of $2001.71, which was $1.07 over the Medicaid limit, and Resident #7 had a balance of $1,867.63. There was no documentation indicating that the required notifications were made to either resident or their legal representatives. During interviews, the Nursing Home Administrator (NHA) and Business Office Manager (BOM) acknowledged the oversight. The BOM discovered the discrepancies and stated that she would notify the residents or their legal representatives and audit all residents' accounts to ensure compliance. The facility's policy mandates that residents receiving Medicaid benefits must be notified when their account balance approaches the eligibility resource limit to prevent loss of Medicaid eligibility.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that Resident #1 was free from potential sexual abuse by Resident #20. On 4/19/24, Resident #20 inappropriately touched and attempted to kiss Resident #1 in a high visual common area of the facility. The incident lasted for over ten minutes before a staff member intervened. Resident #1, who was unable to speak and had severe cognitive impairments, was positioned in a recliner when Resident #20, who has a history of inappropriate behaviors, approached her and began to touch her inappropriately. The facility's video surveillance captured the entire incident, and it was reported to the nursing home administrator (NHA) by a certified nurse aide with medication aide authority (CNA-Med) #2. A physical assessment of Resident #1 showed no obvious injury, but the incident highlighted a significant lapse in supervision and protection for the residents involved. Resident #20, who has diagnoses including Parkinson's disease, dementia with behavioral disturbances, and other sexual dysfunctions, had a care plan that included interventions for managing his inappropriate behaviors. However, the care plan did not include new interventions after the 4/19/24 incident to prevent recurrence. The facility placed Resident #20 on 15-minute checks and educated staff to always have two staff members present when providing care for him. Despite these measures, the facility's response was inadequate as it failed to document staff interviews and did not implement sufficient preventive measures. Interviews with staff revealed a lack of awareness and specific precautions regarding Resident #20's behaviors. CNA #2, who was seen on video walking past the incident while using her cell phone, was instructed to be more attentive. The NHA admitted to conducting an informal education huddle with staff but did not document the training provided. The facility's investigation was primarily based on video footage, and the NHA did not document interviews with staff or residents. This lack of thorough documentation and follow-up indicates a failure to ensure a safe environment for all residents, particularly those with cognitive impairments like Resident #1.
Failure to Ensure Residents Are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not evaluate Resident #1 for the use of a restraint, obtain a signed consent, or secure a physician's order for the restraint. Additionally, the facility did not complete quarterly safety risk assessments, document less restrictive measures attempted, or conduct trial periods without the restraints for Resident #1. Observations revealed that Resident #1 was consistently wearing a one-piece outfit with a zipper on the back, which she could not remove herself, effectively acting as a restraint. Interviews with staff indicated a lack of awareness that the outfit was considered a restraint, and there was no documentation of other interventions attempted to prevent the resident from removing her clothes in public areas. Resident #27 was also subjected to physical restraints without proper documentation and evaluation. The resident's care plan included the use of a Lap Buddy and a wanderguard, but the facility failed to document the risks versus benefits of these restraints or conduct trial periods without them. Observations showed Resident #27 using the Lap Buddy and wanderguard daily, and staff interviews confirmed that these restraints were in place due to the resident's history of wandering and poor safety awareness. However, there was no documentation of other interventions attempted or the necessity of continued use of these restraints. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used for the safety and well-being of the resident after other alternatives have been tried unsuccessfully. The policy also requires a written order from a physician, consent from the resident or their representative, and ongoing re-evaluation of the need for restraints. The facility failed to adhere to these guidelines for both Resident #1 and Resident #27, resulting in the inappropriate use of physical restraints without proper evaluation, documentation, or consent.
Deficiency in Restorative and Occupational Therapy Services
Penalty
Summary
The facility failed to provide appropriate restorative therapy services to two residents with limited range of motion, leading to deficiencies in their care. Resident #57, who had diagnoses including dementia and COPD, was not receiving the required restorative therapy services for bed mobility, transfers, and other activities of daily living (ADLs). Despite a care plan indicating the need for six days a week of therapy, documentation showed that these services were inconsistently provided, with no recorded refusals from the resident. The resident expressed concerns about the lack of therapy and its impact on his mobility and ability to perform ADLs. Similarly, Resident #36, diagnosed with cerebral palsy and osteoarthritis, did not receive the necessary restorative and occupational therapy services. The resident's care plan also required six days a week of restorative therapy, but documentation revealed significant gaps in service provision. Additionally, there was a physician's order error for occupational therapy, which was not corrected, resulting in the resident receiving far fewer therapy sessions than needed. The resident reported increased difficulty with mobility and transfers due to the lack of therapy. Interviews with staff, including the restorative aide, director of rehabilitation, and nursing home administrator, confirmed the inconsistencies in providing restorative and occupational therapy services. The facility faced challenges such as therapy staff shortages and unclear responsibilities among CNAs and NAs regarding restorative care. The director of nursing and the nursing home administrator acknowledged the deficiencies and the impact on the residents' care, highlighting systemic issues in therapy service delivery and documentation.
Failure to Ensure Proper Respiratory Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper respiratory treatment and care. Specifically, the facility did not administer oxygen in accordance with the physician's order, did not ensure staff reminded and encouraged the resident to wear his oxygen, and did not ensure clear communication regarding when the resident should use his oxygen. The resident, who had severe cognitive impairment and multiple diagnoses including chronic obstructive pulmonary disease (COPD) and hypoxemia, was observed multiple times without his oxygen cannula in place, despite having an oxygen canister attached to his wheelchair. Staff members walked past the resident without encouraging or assisting him to wear his oxygen, and the resident himself mentioned that his oxygen comes off his face sometimes. The resident was observed without his oxygen for extended periods, and staff did not check his oxygen saturation levels after these periods of non-use. The resident's care plan and computerized physician orders (CPO) indicated that he required oxygen via nasal cannula at 2 liters per minute and that his oxygen saturation levels should be checked daily and as needed to maintain a saturation level of 90% or greater. However, the CPO did not specify how often the resident needed to wear oxygen. The care plan included various interventions to manage the resident's respiratory status, but it did not address the resident's tendency to remove his oxygen or provide specific interventions for when he refused to wear it. Interviews with staff revealed that they were aware the resident should wear his oxygen at all times but did not consistently remind or assist him to do so. The Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged that the resident's care plan did not include interventions for when he refused his oxygen and that staff should check his oxygen saturation levels when he did not wear his oxygen. The facility's failure to ensure the resident received proper respiratory care was evident in multiple observations and staff interviews. The resident was frequently seen without his oxygen, and staff did not consistently encourage or assist him to wear it. The care plan and CPO lacked clear directives on how often the resident needed to wear oxygen and did not address the resident's tendency to remove it. The DON and NHA admitted that the resident's oxygen needs and refusals had not been adequately discussed in quality assurance meetings, and staff were not consistently checking the resident's oxygen saturation levels after periods of non-use.
Failure to Properly Store and Monitor Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards. Specifically, the facility did not maintain appropriate storage temperatures for refrigerated medications and allowed expired medications to remain in use. Observations revealed that medication storage cart G/H contained an expired bottle of milk of magnesia, and medication storage cart A/B held expired containers of alprazolam and ondansetron. Additionally, the medication room refrigerator lacked a temperature log, and temperature documentation was incomplete for several days in March and April 2024, and entirely missing for May 2024 up to the date of the survey. Interviews with staff, including a registered nurse (RN), a certified nurse aide with medication authority (CNA-Med), the nursing home administrator (NHA), and the director of nursing (DON), confirmed the presence of expired medications and the failure to log refrigerator temperatures. The NHA acknowledged that the responsibility for logging refrigerator temperatures had recently shifted from maintenance to nursing staff, resulting in missed documentation. The DON emphasized the importance of logging temperatures to ensure medication safety and effectiveness, and noted that night shift medication technicians were responsible for checking medication carts, which had not been done consistently.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cortez
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Rehabilitation And Healthcare Center, The | 20.3 mi | — | 3 | 0 |
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