Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control requirements at Vista Manor Nursing Center during the annual survey.
Findings
The facility failed to ensure proper infection control practices, specifically hand hygiene and glove use by staff, which had the potential to compromise resident health and safety. Observations and interviews confirmed staff did not perform hand hygiene consistently when changing gloves or after contact with residents' environments.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program.
Report Facts
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational therapist A | Occupational Therapist | Named in infection control deficiency for failure to perform hand hygiene and proper glove use |
| Certified nursing assistant B | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene after touching resident's environment |
| Director of Nursing | Director of Nursing | Confirmed infection control policy and staff responsibilities regarding glove use and hand hygiene |
| Infection Preventionist | Infection Preventionist | Confirmed facility policies on hand hygiene and glove use |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 11, 2024
Visit Reason
The inspection was conducted based on complaint investigations related to food safety, infection prevention and control practices, and equipment maintenance at Vista Manor Nursing Center.
Complaint Details
The complaint investigation focused on infection prevention failures for Residents 19 and 64 under enhanced barrier precautions, and food safety and equipment maintenance issues. Substantiation status is not explicitly stated.
Findings
The facility failed to maintain proper food storage and sanitation in the kitchen, ensure infection prevention practices for residents under enhanced barrier precautions, and maintain essential equipment safely. Specific issues included undated food items, ice buildup in freezers, dust on kitchen equipment, improper PPE use by staff and family members, and hazardous conditions with resident equipment.
Deficiencies (3)
Several food items were undated for use by dates in refrigerators, freezers, and dry goods area; ice buildup on Dessert Freezer #2; dust accumulation on a black electric fan; black residue on caulking of dishwasher and 3-compartment sink.
Failure to ensure infection prevention practices for residents under enhanced barrier precautions, including improper PPE use by staff during medication administration and family member assisting care.
Failure to maintain equipment safely: Resident 10's bedside rolling table edge trimmings were peeling and bed footboard was wobbly, posing hazard.
Report Facts
Residents affected: Some
Residents affected: Few
Medication frequency: 8
Medication duration: 6
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in infection prevention deficiency for not wearing gown during intravenous medication administration |
| LVN C | Licensed Vocational Nurse | Involved in reminding family member about PPE use and interviewed regarding equipment maintenance |
| LVN D | Licensed Vocational Nurse | Observed and interviewed during infection prevention observations and tube feeding |
| CNA G | Certified Nursing Assistant | Observed transferring Resident 64 and involved in PPE reminder to family member |
Inspection Report
Routine
Deficiencies: 11
Date: Oct 7, 2022
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including review of resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to timely notify residents of Medicare non-coverage, incomplete employee background checks, lack of comprehensive care plans for residents, improper medication administration practices, expired medications storage, inadequate monitoring of psychotropic medications, medication errors, unsafe food storage practices, and multiple infection control lapses including improper use of PPE, failure to disinfect equipment, and unlabeled oxygen tubing.
Deficiencies (11)
Failure to ensure timely Notice of Medicare Non-Coverage (NOMNC) to resident discharged from Medicare Part A services.
Failure to conduct background check prior to hiring one employee.
Failure to develop complete care plans addressing residents' needs including insulin use, oxygen use, antidepressant medication, and anticoagulant use for four residents.
Licensed nurse forcefully administered medication via gastric tube causing leakage.
Failure to follow physician's order to apply compression stockings as prescribed.
Expired medications found in medication rooms and emergency kit.
Failure to monitor side effects and target behaviors for psychotropic medications and failure to complete required AIMS assessment.
Medication error rate of 17.6% observed during medication administration including missed doses, improper timing, and incorrect administration techniques.
Failure to ensure food was stored and labeled properly including lack of internal thermometers in refrigerators and unlabeled resident food.
Multiple infection control failures including improper use of N95 masks, failure to disinfect equipment, unlabeled and undated oxygen tubing, failure to perform hand hygiene during medication pass, improper storage of nebulizer mask, failure to screen staff for COVID-19 symptoms, and unclean oxygen concentrator filter.
Unsafe practice of using paper towels to light oven pilot light.
Report Facts
Deficiencies cited: 11
Medication error rate: 17.6
Residents sampled: 18
Residents affected: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Certified Nursing Assistant | Named in background check deficiency related to lack of documentation of pre-hire screening |
| A | Licensed Vocational Nurse | Named in medication administration deficiency for forceful gastric tube medication administration and insulin administration timing |
| C | Licensed Vocational Nurse | Named in medication error deficiency for missed medication and hand hygiene lapses |
| E | Licensed Vocational Nurse | Named in medication error deficiency for improper medication administration and infection control lapses |
| F | Nurse Supervisor | Named in infection control deficiencies including unlabeled oxygen tubing and unclean oxygen concentrator filter |
| I | Certified Nursing Assistant | Named in infection control deficiency for failure to disinfect vital signs machine |
| K | Certified Nursing Assistant | Named in infection control deficiency for failure to undergo COVID-19 screening prior to facility entry |
| M | Licensed Vocational Nurse | Named in deficiency related to improper application of compression stockings |
| DSD | Director of Staff Development | Interviewed regarding employee background check deficiency |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including care plans, medication administration, infection control, and policy compliance |
| IP | Infection Preventionist | Interviewed regarding infection control deficiencies and staff PPE use |
| RD | Registered Dietitian | Interviewed regarding food storage and safety deficiencies |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 19, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, safety, medication management, fall prevention, food and nutrition services, infection control, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during medication administration, inadequate fall prevention interventions, improper disposal of controlled substances, high medication error rates, improper medication storage and sanitation, insufficient dietary staff competencies, unsanitary food storage and preparation conditions, and failure to follow infection control practices during medication passes.
Deficiencies (8)
Failed to ensure privacy and dignity for two residents during medication administration, exposing them to public view.
Failed to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in repeated falls for two residents.
Failed to ensure controlled substance medications were disposed properly, with one nurse disposing medication without co-signature.
Medication error rate of 42.86% with 12 errors during 28 opportunities observed, including wrong dose, missed medications, and improper administration timing.
Failed to properly store medications in a safe and sanitary condition; medication carts and emergency carts contained multi-color sticky substances, expired medications, and improperly stored medications.
Dietary staff lacked knowledge and skills to properly check thermometer calibration and sanitizer concentration, risking food safety.
Failed to maintain sanitary conditions in the kitchen including uncovered hair, dirty ice machine and equipment, expired and improperly stored food items, and expired sanitizer test strips.
Failed to ensure nurse staff followed proper infection control practices during medication passes, including improper glove use, failure to perform hand hygiene, and exposed catheter tubing tip.
Report Facts
Medication error rate: 42.86
Medication errors: 12
Medication opportunities: 28
Residents affected: 2
Residents affected: 2
Residents affected: 7
Residents affected: 10
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in controlled substance disposal deficiency |
| RN E | Registered Nurse | Named in medication error and infection control deficiencies |
| LVN C | Licensed Vocational Nurse | Named in privacy, medication error, and infection control deficiencies |
| LVN D | Licensed Vocational Nurse | Named in privacy deficiency |
| LVN G | Licensed Vocational Nurse | Named in medication error and infection control deficiencies |
| LVN H | Licensed Vocational Nurse | Named in medication error and infection control deficiencies |
| RN I | Registered Nurse | Named in medication error and infection control deficiencies |
| RN J | Registered Nurse | Named in medication error and infection control deficiencies |
| RN A | Registered Nurse | Named in medication storage and infection control deficiencies |
| DA P | Dietary Aide | Named in dietary staff competency and sanitizer testing deficiencies |
| DS | Dietary Supervisor | Named in dietary staff competency and kitchen sanitation deficiencies |
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