A list of the most recent deficiencies for College Vista Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-14 | 2024-03-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-16 | 2023-12-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-12 | 2022-08-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-02 | 2022-06-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-20 | 2022-06-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-05-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-03 | 2022-05-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-03 | 2022-05-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-21 | 2022-04-20 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-22 | 2022-03-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-30 | 2022-01-19 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-11-16 | 2022-01-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-19 | 2021-12-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-19 | 2021-12-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-11-19 | 2021-12-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-19 | 2021-12-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-19 | 2021-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2021-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-21 | N |
| Have policies on smoking. | Health | 2021-11-19 | 2021-12-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-09-17 | 2021-10-07 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-09-10 | 2021-09-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-04-29 | 2021-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-29 | 2021-05-19 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-05-03 | 2019-06-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-03 | 2019-06-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-03 | 2019-06-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-03 | 2019-06-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-06-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-03 | 2019-06-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-03 | 2019-06-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-03 | 2019-06-27 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-06-03 | 2019-06-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-03 | 2019-06-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-31 | 2018-07-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-31 | 2018-07-06 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-05-12 | 2018-06-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-12 | 2018-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-12 | 2018-06-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-12 | 2018-06-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-12 | 2018-06-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-05-12 | 2018-06-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-12 | 2018-06-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-05-12 | 2018-06-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-05-12 | 2018-06-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-05-12 | 2018-06-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-12 | 2018-06-22 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-05-12 | 2018-06-22 | N |
