Inspection Report
Re-Inspection
Deficiencies: 0
Dec 15, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2025-12-12, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2025-11-18
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 13
Nov 18, 2025
Visit Reason
Resurvey with attached complaints conducted on 11/12/25, 11/13/25, 11/17/25, and 11/18/25 at Oxford Vista Senior Living, an assisted living facility.
Findings
The facility failed to meet multiple regulatory requirements including proper documentation and revision of negotiated service agreements, ensuring safety measures for wandering residents, proper labeling of over-the-counter medications, complete incident documentation, quarterly emergency management plan reviews, safe food preparation and storage, infection control including tuberculosis screening compliance, and secure storage of chemicals.
Complaint Details
The visit was a resurvey with attached complaints numbered 197363, 197345, 197342, 197188, 197331, 197349, 197329, 197158, 196930, 196885, 196499, 196311, 196268, 196307, 196125, 197422, 197381, 197382, 197392, and 197377.
Severity Breakdown
SS=E: 6
SS=D: 1
SS=F: 6
Deficiencies (13)
| Description | Severity |
|---|---|
| Negotiated Service Agreements (NSAs) for several residents failed to describe services based on Functional Capacity Screens (FCSs). | SS=E |
| NSAs were not revised annually or after significant changes in condition for some residents. | SS=E |
| NSAs lacked signatures of all individuals involved in their development. | SS=D |
| NSAs failed to name the licensed nurse responsible for implementation and supervision of healthcare service plans. | SS=E |
| Failure to provide pagers to direct-care staff in memory care and assisted living units to ensure safety of wandering residents and failure to post warning signs at exit doors. | SS=F |
| Over-the-counter medications were not labeled with the full name of the resident. | SS=E |
| Incomplete documentation of incidents, symptoms, and actions taken for several residents. | SS=E |
| Lack of documentation of quarterly reviews of the facility's emergency management plan with staff and residents. | SS=F |
| Failure to document food temperatures and ensure food items were served at proper temperatures. | SS=F |
| Food items were stored uncovered, undated, or unlabeled in refrigerators and freezers. | SS=F |
| No disposable towels available at sinks in dining rooms for hand drying, compromising sanitary conditions. | SS=F |
| Failure to comply with tuberculosis screening guidelines for new residents and staff, including late or missing two-step TB skin tests and symptom screening. | SS=F |
| Chemicals were stored unlocked in assisted living unit kitchen and closets, posing safety risks. | SS=E |
Report Facts
Residents at risk for wandering: 6
Residents requiring physical assistance: 15
OTC medications not labeled: 17
Days late TB skin test: 70
Days late TB skin test: 49
Days late TB skin test: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Administrative Nurse | Confirmed multiple deficiencies including late TB tests, missing signatures, and incomplete documentation. |
| Administrative Nurse D | Administrative Nurse | Documented incident involving resident wandering and injury. |
| Administrative Staff B | Administrative Staff | Confirmed lack of emergency plan reviews and chemical storage expectations. |
| Maintenance Staff E | Maintenance Staff | Acknowledged lack of paper towels and provided pagers for memory care staff. |
| Certified Medication Aide F | Certified Medication Aide | Reported no pager during resident wandering incident. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 18, 2025
Visit Reason
This document represents the provider's plan of correction following a resurvey with multiple attached complaints conducted on 11/12/25, 11/13/25, 11/17/25, and 11/18/25 at the assisted living facility.
Findings
The plan of correction addresses findings from a resurvey and numerous complaints identified during the inspection visits in November 2025.
Complaint Details
The plan of correction is related to attached complaints with IDs 197363, 197345, 197342, 197188, 197331, 197349, 197329, 197158, 196930, 196885, 196499, 196311, 196268, 196307, 196125, 197422, 197381, 197382, 197392, and 197377.
Inspection Report
Follow-Up
Deficiencies: 5
May 29, 2025
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1), 26-41-101 (f)(3), 26-41-204 (i), 26-41-205 (d)(1-2), and 26-41-105 (f)(11) were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(1) |
| Deficiency related to regulation 26-41-101 (f)(3) |
| Deficiency related to regulation 26-41-204 (i) |
| Deficiency related to regulation 26-41-205 (d)(1-2) |
| Deficiency related to regulation 26-41-105 (f)(11) |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 5
Apr 29, 2025
Visit Reason
The inspection was an abbreviated survey conducted in response to multiple complaints (#195079, 195080, 194954, 194362, 194367, 193187, and 192282) regarding the facility.
Findings
The facility was found to have immediate jeopardy related to insufficient staffing in a secured specialty unit leading to a resident elopement. Additional findings included failure to report and investigate allegations of abuse or neglect timely, inadequate training and documentation for Certified Medication Aides, medication administration errors, and incomplete documentation of incidents in resident records.
Complaint Details
The investigation was triggered by multiple complaints alleging neglect and abuse, including a resident elopement incident where a resident left a secured unit unsupervised for approximately 83 minutes and was found by police about 0.5 miles away. The facility failed to provide adequate staffing and timely reporting and investigation of abuse allegations.
Severity Breakdown
ANE: 1
E: 1
F: 1
D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide sufficient staffing in secured specialty unit resulting in resident elopement and immediate jeopardy. | ANE |
| Failure to report and investigate allegations of abuse or neglect within required timeframes and submit reports to the department. | E |
| Failure to ensure health care services were provided by qualified staff with proper training and ongoing education for Certified Medication Aides. | F |
| Failure to administer medications according to medical orders and professional standards, including a medication error involving wrong medication given. | D |
| Failure to document all incidents, symptoms, and indications of illness or injury including date, time, actions taken, and results in resident records. | D |
Report Facts
Resident census: 44
Residents in secured specialty unit: 20
Duration resident was away: 83
Residents at risk for elopement: 16
Medication error dose: 0.25
Medication order dose: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN A | Licensed Nurse | Named in findings related to resident elopement, medication administration, and failure to report abuse allegations |
| CMA B | Certified Medication Aide | Named in findings related to resident elopement and medication administration |
| Administrator C | Administrator | Named in findings related to staffing, reporting, investigation, and training deficiencies |
| Director of Clinical Services G | Director of Clinical Services | Named in findings related to medication administration and documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 29, 2025
Visit Reason
The document is a plan of correction responding to findings from an abbreviated survey conducted for multiple complaints against the facility on 04/29/25, 04/30/25, and 05/01/25.
Findings
The plan of correction addresses citations resulting from an abbreviated survey related to complaints numbered 195079, 195080, 194954, 194362, 194367, 193187, and 192282.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 12, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-28.
Findings
All deficiencies have been corrected as of the compliance date of 2024-11-08 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Original Licensing
Census: 31
Deficiencies: 6
Oct 22, 2024
Visit Reason
Initial certification survey with a complaint #189585 conducted at Oxford Vista Senior Living, an assisted living facility.
Findings
The survey found multiple deficiencies including failure to fully develop negotiated service agreements based on residents' functional capacity screenings, failure to revise service agreements after significant changes, lack of licensed nurse coordination for health care services, incomplete documentation of incidents, and failure to ensure sanitary conditions in the kitchen.
Complaint Details
The visit was triggered by complaint #189585.
Severity Breakdown
E: 1
D: 3
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the Negotiated Service Agreement/Healthcare Service Plan (NSA/HCSP) was fully developed based on the resident's Functional Capacity Screen, service needs, and preferences for residents R101 and R103. | E |
| Failed to ensure designated staff revised the NSA/HCSP when R103 received services from an outside provider for physical therapy and occupational therapy. | D |
| Failed to ensure a licensed nurse provided or coordinated necessary health care services, including assessment for use of bed rails and confirmation that bed rails were not restraints for resident R103. | D |
| Failed to ensure the NSA/HCSP identified the licensed nurse responsible for implementation and supervision of the health care services plan for residents R101 and R103. | F |
| Failed to ensure resident R101's record contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results. | D |
| Failed to ensure sanitary conditions for food service by not documenting daily hot water temperature and chemical strengths in the memory care unit kitchen. | F |
Report Facts
Census: 31
Memory care unit residents: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Interviewed regarding deficiencies in service agreements and care plans for residents R101 and R103. |
| Administrative Staff A | Administrative Staff | Acknowledged lack of documentation regarding an elopement incident for resident R101. |
| Dining Services Director C | Dining Services Director | Interviewed about dishwasher temperature logs in the memory care unit kitchen. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 22, 2024
Visit Reason
The document is a plan of correction related to an initial certification survey with a complaint #189585 conducted at an Assisted Living facility on 10/22/24 and 10/28/24.
Findings
The citations represent findings from the initial certification survey combined with a complaint investigation at the assisted living facility.
Complaint Details
The visit was triggered by complaint #189585 as part of the initial certification survey.
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