Inspection Reports for Vista Hills Health Care Center

The complaint investigation found that Resident #1 sustained a spiral femur fracture during repositioning by a CNA, and the facility delayed transfer to hospital by approximately 7 hours after radiologist confirmed the fracture. The delay was due to failure of nursing staff to follow up on STAT x-ray results during the night shift. The facility conducted an internal investigation, suspended and retrained the CNA, and provided in-service training to all staff.

The facility failed to ensure timely transfer of Resident #1 to a hospital after a radiologist confirmed a spiral femur fracture on 05/29/2025, resulting in a 7-hour delay in emergency care. Additionally, the facility failed to provide adequate supervision and safe handling during repositioning, which caused the fracture. The facility conducted corrective actions including staff retraining and in-service education.

The complaint investigation revealed that Resident #1 did not receive four doses of Entresto Oral Tablet on 03/29/25 and 03/30/25 due to medication unavailability. The facility failed to notify the physician or document such notification in the resident's progress notes. Interviews with staff confirmed the failure to notify and administer medication as ordered.

The facility failed to immediately notify the physician when Resident #1 did not receive the prescribed Entresto medication due to lack of availability, and failed to administer the medication as ordered. This failure could place residents at risk of delayed medical treatment and inadequate therapeutic outcomes.

The facility failed to ensure that Resident #8's urinary catheter leg strap was secured, which could cause catheter pulling and discomfort. Interviews with staff revealed lapses in routine checks for catheter strap placement, despite training and policies requiring such checks.

The facility was found deficient in multiple areas including failure to address resident grievances especially regarding cold food temperatures, failure to maintain resident privacy during care plan meetings, inadequate assistance with activities of daily living for a resident, improper pharmaceutical services including controlled substance counts, unsafe medication storage, failure to maintain food at safe temperatures, poor kitchen sanitation and food storage practices, and unsafe environmental conditions such as broken tiles and rusted drains in the shower room.

The facility failed to ensure that assessments accurately reflected the resident's status for one resident (Resident #5) out of seven reviewed. Resident #5's behaviors were not documented on the annual MDS assessment, which could result in residents not receiving correct care and services.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #6 that included the physician-ordered intervention of elevating the head of the bed at least 30 degrees during continuous enteral feeding. This failure placed the resident at risk for aspiration. Observations and interviews confirmed inconsistent adherence to this intervention despite staff training and policies.

The facility failed to ensure that Resident #5's feeding tube bags were properly labeled with the resident's name, date, and time the administration began, which could risk incorrect feeding and delayed care. Despite this, Resident #5 had no significant weight loss or complications related to tube feeding.

The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, incomplete care plans addressing resident behaviors, inadequate treatment and care per physician orders, improper pressure ulcer care, failure to post nurse staffing information timely, medication storage issues, incomplete medical record documentation, and infection control lapses such as improper storage of used gowns and treatment supplies.

The facility failed to ensure residents were free from physical restraints without medical indication, failed to provide timely pharmaceutical services including medication refills and lab monitoring for Resident #3, and failed to enforce proper food safety practices such as wearing hair nets and beard guards in the kitchen.

The investigation was complaint-driven based on allegations of abuse and neglect related to bruising of unknown origin on Resident #1. The bruising was initially attributed to a tight brief by staff, and the facility failed to report the injury timely to the state agency. Family members expressed concerns about the investigation and lack of a Sexual Assault Nursing Examination (SANE). Adult Protective Services (APS) and police were involved. The facility also failed to complete proper documentation for Resident #1's transfer to the emergency room.

The facility failed to implement and follow policies to prevent abuse, neglect, and exploitation, failed to timely report injuries of unknown origin to the state agency, and did not properly investigate allegations of abuse. Resident #1 had bruising of unknown origin that was initially attributed to a tight brief without proper reporting. The facility also failed to complete a transfer/discharge form when Resident #1 was sent to the emergency room. Additionally, Resident #2 did not receive prescribed pain medication (Lyrica) for nine doses due to pharmacy and prescription delays.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, particularly regarding fall interventions such as the use of a fall mat and bed positioning, as well as activities of daily living. This deficiency could place residents at risk of not receiving necessary care or personalized plans to address their needs.

The complaint investigation focused on Resident #1's right foot necrotic tissue discovered on 09/22/23. The RP was not notified until the day before a podiatrist visit, and the facility lacked documentation of family notification. Interviews with staff confirmed failure to complete SBAR assessments and inconsistent communication with family. Resident #1's wound care was documented but incomplete. Resident #3's care plan did not include hospice care despite admission to hospice on 09/05/23.

The facility failed to notify Resident #1's RP about the necrotic tissue on 09/22/23 and did not complete an SBAR assessment documenting notification. Resident #1's wound care documentation was incomplete and inaccurate. For Resident #3, the facility failed to include hospice care in the care plan. These failures could place residents at risk of inadequate care and lack of family involvement in treatment decisions.

The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to ensure accurate assessments and care plans reflecting residents' needs, inadequate provision of individualized activities, improper catheter care, unlabeled enteral feeding formula, lack of oxygen signage, inaccurate medication administration documentation, food labeling deficiencies, and infection control lapses related to linen storage and gastrostomy tube care.

The facility was found deficient in providing reasonable accommodation for a resident's call light needs, ensuring proper nail care for a cognitively impaired resident, and securing a urinary catheter properly to prevent infection and injury. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The facility was found deficient in developing baseline care plans within 48 hours for newly admitted or readmitted residents, proper repositioning techniques to prevent injury, securing foley catheters to prevent infection, and posting daily nurse staffing information. These deficiencies posed risks of inadequate care, injury, infection, and lack of transparency for residents and visitors.

The investigation was complaint-driven, focusing on concerns about wound care and feeding tube labeling. Resident #2's wound care was not consistently provided or documented as ordered, and Resident #1's feeding tube bag lacked proper labeling. Interviews with staff revealed gaps in care and documentation, with some responsible nurses unavailable or no longer employed.

The facility failed to complete wound care treatments as ordered for Resident #2's skin tears, resulting in potential risk of wound infection. Additionally, the facility failed to ensure Resident #1's feeding tube bag was labeled with her name, risking incorrect feeding formula administration. Documentation of wound care treatments for Resident #2 was also found to be inaccurate.

The complaint involved an allegation by Resident #3 of abuse including hair pulling, being drugged, and raped. The allegation was reported on 4/18/2023. The facility conducted a preliminary investigation but did not complete it thoroughly. Resident #3 denied abuse and stated confusion after waking from a dream. The family was contacted and chose not to pursue further action. The police were notified and Resident #3 was assessed with no injuries found.

The facility failed to thoroughly investigate and report the abuse allegation involving Resident #3 within 5 working days as required. The investigation report was incomplete, and documentation of Safe Surveys and in-services on Abuse and Neglect was missing. Resident #3 denied abuse, and the family declined further action after being informed.

The facility was found deficient in multiple areas including failure to maintain a clean environment, improper use of physical restraints, failure to timely report abuse allegations, incomplete and untimely care plans, inadequate catheter care, failure to follow dietary recommendations leading to weight loss, improper use and monitoring of psychotropic medications, unlocked medication cart, and food safety violations including serving cold food and improper food storage.