Splendido At Rancho Vistoso

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights for one Resident (#6) out of the four sampled residents to be free from physical abuse by another resident (#10). The deficient practice could result in other residents being abused.Finding include--Regarding Resident #6Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression with psychotic symptoms, anxiety, and insomnia.A quarterly MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 15, which indicated intact cognition. The mood assessment revealed that the resident felt down, depressed, or hopeless in 2 -6 days of the assessment.A behavior progress note dated May 27, 2026, revealed that the Resident was involved in a resident to resident altercation involving slapping the arm of another resident. The note indicated no injuries were noted and that the resident admitted she had no intent to harm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure that there were no expired over the counter medications, nutritional supplements and syringes readily available for resident use, the sample size is 38 residents. The deficient practice could result in an increased risk for side effects. Findings include: On March 26, 2025 at 7:51 A.M. an observation of a medication preparation was conducted for Resident # 287 by staff Registered Nurse (RN / staff #122). Aspirin 81 oral tablet delayed release 81 mg was prepared for the resident, the medication was found to have an expiration date of August 2023. The expiration date was brought to the attention of RN / staff #122, who immediately disposed of the medication. The medication was not given to resident #287. A new bottle was retrieved from the medication supply room. Medication was prepared and dispensed without incident for the involved resident. Following the observation conducted on March 26, 2025 at 7:51 A.M., an interview was conducted with RN / staff #122, who stated that the medication was provided by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of policies and procedures, the facility failed to ensure food storage and service were in accordance with professional standards regarding storing of food boxes and staff wearing a bonnet. The deficient practices could increase the risk for foodborne illness. Findings include: An observation on March 25, 2025 at 10:00 a.m. revealed boxes in the refrigerator and freezer on the top shelf. These items were too close to the ceiling. The boxes included: four boxes of spinach, half & half, whipping cream, and broccoli in the refrigerator. In the freezer: cookies, fudge bars, wheat, bakers misc., royal Danish pastries. All the boxes were on the top shelf blocking the sprinkler system. A return observation occurred on March 26, 2025 at 10:40 a.m. The boxes were still stacked on the top shelf in the refrigerator and the freezer. An observation on March 26, 2025 at 10:30 a.m. showed a red line on the wall in the main kitchen area. The line is used to ensure boxes/items are not stacked higher than is appropriate. An observation was conducted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, observations, and policy review, the facility failed to ensure that medications were not left unattended on a bedside table for one of 44 sampled residents(#142).The deficient practice could result in medications not being administered as ordered or another resident/person consuming the medication. Findings include: Resident (#142) was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, paroxysmal atrial fibrillation, type 2 diabetes mellitus and hypertension. An admission Minimum Data Set ( MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A care plan initiated on March 18, 2025 revealed no evidence of a focus or interventions regarding self-administration of medications. A physician order dated March 18, 2025, revealed the following: -Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT-two puff inhale orally every 4 hours as needed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record, staff interviews and facility policy, the facility failed to ensure that medications were administered as ordered by the physician for 1 resident (#21). This practice could result in decreased deep vein thrombosis prophylaxis. Findings include: Resident #21 was admitted on [DATE] with diagnose of personal history of transient ischemic attack, cerebral infarction, and cardiac septal defect. A care plan dated April 14, 2023 included that the resident has Cerebral Vascular Accident and history of transient ischemic attack with an intervention of giving medications as ordered by the physician. A physician's order dated June 24, 2023 included Aspirin Oral Tablet Chewable (Aspirin), Give 81 mg by mouth one time a day for deep vein thrombosis prophylaxis. An observation was conducted on October 19, 2023 at 7:32 AM of a Registered Nurse (RN/staff #32) administering a 81mg enteric coated aspirin to resident #21 An interview was conducted on October 19, 2023 at 10:41 a.m. with the RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and policy review, the facility failed to ensure that cleaning clothes were stored in accordance with professional standards and that a beard nets were worn by two staff member. The deficient practice could result in placing residents at risk for food-borne illnesses. Findings include: A kitchen observation was conducted on October 17, 2023 at 8:40 AM. The observation revealed a dry cleaning rag on the top shelf of the central food preparation area adjacent to the plating area. Two additional rags were observed on a shelf above the sink in the main kitchen area, directly on top of a sealed bag of pita pocket bread. The executive chef took pictures of each identified rag and its placement. An interview was conducted immediately thereafter with the executive chef, staff #110, who stated that the expectation was the cleaning rags are to be stored underneath the counters and not on food preparation or storage areas. He stated that the risk could include a potential for infection or foodborne illness. A kitchen observation was conducted on October…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and facility policy, the facility failed to monitor target behaviors and adverse effects for three residents receiving pyschotropic medications (#1, #17, and #7). The sample size was five residents. The deficient practice could result in residents receiving psychotropic medications without adequate monitoring. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, and Parkinson's disease. Review of the resident's psychotropic medication care plan, revised May 24, 2022 revealed the resident was taking psychotropic medications related to depression, anxiety, and hallucinations. The care plan noted the resident struggles with loss of independence and continual physical decline. Interventions included monitoring for adverse effects, and monitor/record occurrence of target behavior symptoms and document per facility policy. Review of June 2022 recapitulation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and interviews, the facility failed to ensure one resident's (#23) call light and water was accessible. The deficient practice could result in residents' needs not being met. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and anxiety disorder. Review of the resident's fall care plan, revised on April 21, 2022, revealed the resident was at risk for falls due to being a new admission. Interventions included to keep the call light within reach when the resident is in her room, keep personal items within reach, and provide routine rounds to address the resident's needs. A quarterly Minimum Data Set (MDS) assessment, dated July 26, 2022, revealed a BIMS (Brief Interview of Mental Status) score of 3, which indicated severe cognitive impairment. The assessment included the resident needed extensive assistance with bed mobility, transfer, toilet use, and personal hygiene. An observation was conducted of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policy, the facility failed to ensure one resident (#140) was monitored for adverse side effects related to anticoagulant use. The sample size was one resident. The deficient practice could result in delayed identification of adverse side effects. Findings include: Resident #140 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, cardiac heart murmur, and hematuria. The physician's orders revealed several orders for warfarin (an anticoagulant medication). These included: -8/20/22 - 1 milligram (mg) per day every Thursday and Sunday for Venous Thrombolism (VTE) prophylaxis. -8/20/22 - 2 mg per day every Monday, Tuesday, Wednesday, Friday, and Saturday for VTE prophylaxis. -8/21/22 - 5 mg per day for VTE prophylaxis -8/22/22 - 3 mg per day one time only for low International Normalized Ratio (INR). An anticoagulant therapy care plan, dated 8/22/22, had a goal to be free from discomfort or adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.