Inspection Reports for Vista Woods Care Center
Three Pennsylvania Place, IA, 525012165
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 1, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending on September 25, 2025, with certification of compliance effective November 26, 2025.
Findings
The facility submitted a credible allegation of compliance and a Plan of Correction for the prior survey. The facility will be certified in compliance effective November 26, 2025. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Sep 25, 2025
Certification effective date: Nov 26, 2025
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 1
Sep 25, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #2561046-C and #2584416-C.
Findings
The facility was found deficient in respecting residents' rights during transportation to and from the shower room, specifically failing to ensure dignity and privacy for residents. The facility has implemented corrective actions including staff training, policy revision, and monitoring to address these issues.
Complaint Details
The visit was triggered by complaints #2561046-C and #2584416-C, both of which resulted in a deficiency.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff respected the dignity of residents while transporting them to and from the shower room, including pulling residents backwards in shower chairs and exposing residents inappropriately. | D |
Report Facts
Resident census: 53
BIMS score: 5
BIMS score: 4
BIMS score: 10
Number of residents observed: 4
Number of residents transported improperly: 3
Number of staff trained: 3
Training dates: Training held on 10/07/2025 and 11/07/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (D.O.N.) | Named in relation to the deficiency and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing (A.D.O.N.) | Named in relation to the deficiency and corrective actions |
| Staff A | Certified Nursing Assistant (CNA) | Observed pulling resident backwards in shower chair |
| Staff B | Certified Nursing Assistant (CNA) | Observed pulling resident backwards in shower chair |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding treatment of residents with dignity |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 16, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective October 11, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification of compliance effective October 11, 2024.
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 3
Sep 9, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from September 9, 2024 to September 12, 2024.
Findings
The facility was found deficient in quality of care related to failure to process physician orders and document treatments for skin conditions in one resident. Additionally, food safety and infection control deficiencies were identified, including failure to serve food under sanitary conditions and failure to follow infection control techniques for one resident with COVID-19.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to process physician orders and document physician ordered treatments such as wound care and dressing changes for 1 of 5 residents reviewed for skin conditions. | Level D |
| Facility staff failed to serve food under sanitary conditions to prevent food borne illness during 1 of 2 meals observed. | Level D |
| Facility failed to follow infection control techniques to prevent potential spread of infection for 1 of 1 residents on transmission-based precautions (Resident #19 with COVID-19). | Level D |
Report Facts
Census: 58
Deficiencies cited: 3
Dates of survey: September 9, 2024 to September 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ron Sturms | Administrator | Signed initial comments on page 1 |
| Staff C | Registered Nurse (RN) | Observed providing wound care and involved in documentation and treatment of Resident #32's wounds |
| Staff A | Certified Nursing Assistant (CNA) | Observed peeling banana and serving food under unsanitary conditions |
| Staff E | Registered Nurse (RN) | Reported on telephone order process and skin assessments |
| Staff F | Registered Nurse (RN) | Responsible for skin assessments and interviewed regarding wound care |
| Staff G | Registered Nurse (RN) | Reported on wound treatment orders and documentation issues |
| Staff H | Registered Nurse (RN) | Requested to look at Resident #32's wounds and involved in infection control |
| Staff D | Certified Nursing Assistant (CNA) | Provided care and assisted Resident #32 |
| Assistant Director of Nursing | Documented treatment orders and care plan revisions for Resident #32 | |
| Director of Nursing | Involved in wound care orders, infection control, and interview statements |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 4, 2024
Visit Reason
The visit was a re-inspection following a prior survey ending April 25, 2024, and an investigation of a facility reported incident 120680-I conducted June 3-4, 2024.
Findings
Vista Woods Care Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities as of May 24, 2024. The facility reported incident 120680-I was not substantiated, and a discretionary denial of payment for new admissions was in effect from May 21 to May 23, 2024.
Report Facts
Discretionary Denial of Payment Duration (days): 3
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 3
Apr 22, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey with an investigation of facility reported incidents #114240 and #117349 from April 22, 2024 to April 25, 2024.
Findings
The facility was found not in compliance with federal regulations due to deficiencies in ensuring residents were free of accident hazards and significant medication errors. Specifically, the facility failed to ensure safe transfer techniques for Resident #14, resulting in a fall with fractures, and failed to properly prime insulin pens for Resident #6 prior to administration.
Severity Breakdown
SS=G: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure staff transferred Resident #14 safely, resulting in a fall causing wrist and femur fractures. | SS=G |
| Failure to ensure residents are free from significant medication errors; specifically, failure to prime insulin pen prior to administration for Resident #6. | SS=D |
| Failure to report a fall with major injury for Resident #14 within required timeframe. | SS=D |
Report Facts
Census: 57
Census: 59
Residents reviewed: 4
Residents reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #14 during fall and transfer, involved in deficiency related to safe transfer |
| Staff A | Licensed Practical Nurse (LPN) | Prepared insulin pen for Resident #6 and involved in deficiency related to medication administration |
| Staff C | Licensed Practical Nurse (LPN) | Witnessed Resident #14 fall but arrived after incident |
| Staff D | Certified Nursing Assistant (CNA) | Provided statements regarding Resident #14's assistance needs and gait belt use |
| Staff E | Certified Nursing Assistant (CNA) | Provided statements regarding gait belt use for Resident #14 |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding Resident #14's assistance needs and fall incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 19, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction, the facility will be certified in compliance effective December 19, 2023.
Inspection Report
Annual Inspection
Deficiencies: 4
Nov 16, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #98238-C, #98723-C, and #108095-C from November 14 to November 16, 2022.
Findings
The facility was found deficient in multiple areas including improper use and monitoring of physical restraints for one resident, failure to provide adequate shaving assistance for a dependent resident, failure to monitor and document behaviors related to psychotropic medication use for one resident, and failure to maintain proper food storage and temperature control in the kitchen.
Complaint Details
The inspection included investigation of complaints #98238-C, #98723-C, and #108095-C.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to assess, monitor, and implement interventions according to standards of practice during the use of a physical restraint (Merry Walker) for one resident, including lack of ongoing monitoring and evaluation. | SS=D |
| Failure to ensure dependent resident received shaving assistance as needed. | SS=D |
| Failure to ensure one resident had ongoing clinical indications for antipsychotic medication and failed to monitor for target behaviors related to medication rationale. | SS=D |
| Failure to provide proper food storage and maintain safe food temperatures, including unlabeled, expired, or improperly stored food items and unsanitary ice machine conditions. | SS=F |
Report Facts
Residents sampled for physical restraints: 27
Residents reviewed for ADL assistance: 26
Residents reviewed for unnecessary medications: 5
Residents potentially affected by food safety issues: 56
Dates of survey: November 14, 2022 to November 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Observed resident R47 in Merry Walker and reported on restraint use. |
| RN1 | Registered Nurse | Observed resident R47 and described restraint unlocking process. |
| MDSC | Minimum Data Set Coordinator | Provided information about restraint classification for resident R47. |
| PT | Physical Therapist | Provided opinion on restraint definition related to Merry Walker. |
| DOR | Director of Rehabilitation | Discussed restraint definitions and practices. |
| COTA | Certified Occupational Therapist Assistant | Confirmed Merry Walker as restraint if resident cannot release latch. |
| DON | Director of Nursing | Discussed restraint policies and monitoring for resident R47 and shaving assistance for resident R48. |
| HA | Hospice Administrator | Discussed assessment of resident R47 for Merry Walker use. |
| Medical Director | Made decision to place resident R47 in Merry Walker and discussed restraint considerations. | |
| LPN1 | Licensed Practical Nurse | Discussed behaviors of resident R13. |
| CNA2 | Certified Nursing Assistant | Reported on behaviors of resident R13 and documentation practices. |
| SSD | Social Services Director | Observed behaviors of resident R13. |
| Consultant Pharmacist | Stated resident R13 should have targeted behavior documentation for psychotropic medication monitoring. | |
| DM | Dietary Manager | Observed food storage and temperature issues in kitchen and snack cart. |
| DA1 | Dietary Aide | Reported on snack cooler ice replenishment practices. |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 1
Apr 29, 2021
Visit Reason
The inspection was conducted as a Recertification Survey for Vista Woods Care Center from April 26 to 29, 2021.
Findings
The facility failed to maintain hot foods at safe temperatures, with food served at temperatures below the required 140 degrees Fahrenheit. Observations, interviews, and policy reviews confirmed this deficiency.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food prepared by methods that conserve nutritive value, flavor, and appearance which is palatable, attractive, and at a safe and appetizing temperature was not maintained; hot foods were served at unsafe temperatures below 140 degrees Fahrenheit. | SS=E |
Report Facts
Census: 37
Food temperature: 104.5
Food temperature: 102.3
Food temperature policy: 140
Inspection Report
Abbreviated Survey
Census: 31
Deficiencies: 0
Mar 4, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted a Focused COVID-19 Infection Control Survey in accordance with Medicare Conditions of Participation and CDC guidance.
Findings
The facility was found to be in compliance with infection control requirements during the focused COVID-19 survey.
Report Facts
Total residents: 31
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 12, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on November 10 - 12, 2020.
Findings
The facility was found in substantial compliance with CMS and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Aug 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and facility reported incident #91419 was conducted by the Department of Inspection and Appeals from August 5 to 11, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Facility reported incident #91419-I was not substantiated.
Complaint Details
Facility reported incident #91419-I was not substantiated.
Inspection Report
Routine
Census: 24
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 16, 2020
Visit Reason
The inspection was conducted as a complaint investigation for complaint number 86915-C.
Findings
The complaint 86915-C was not substantiated according to the findings of the inspection.
Complaint Details
Complaint 86915-C was investigated and found to be not substantiated.
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