Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Knoll Specialized Care Facility during CMS and state inspections, most recent first.
A resident with CHF, prior MI, and muscle weakness was ordered a low air loss mattress for skin integrity, but staff left him sleeping overnight on a mattress topper after the pump was removed from the mattress. He reported asking for the mattress to be changed that night, while staff later described the mattress as underinflated and uncomfortable and said the expectation was to replace a broken LAL mattress as soon as possible for comfort and skin protection.
Unrepaired room damage left a ceiling patch unfinished in one resident’s room and a wall in another resident’s room gouged and damaged from bed collisions. One resident with pneumonitis, Parkinson’s disease, and MDD said he had to look at the ceiling damage all day, while another resident with CHF, MI, and muscle weakness said the wall had been damaged for a while and was not homelike. The DOM and IDON stated the damage should have been repaired in a timely manner and was not homelike.
A resident’s MDS was inaccurately completed when paranoid schizophrenia was entered as an active dx despite psychiatry notes and a VA discharge summary documenting psychosis, major NCD, and no schizophrenia diagnosis. The record also showed olanzapine orders for psychosis-related symptoms, while the DON stated no documentation was found to support the paranoid schizophrenia dx and that MDS dx entries were expected to be reviewed for accuracy.
A resident with BPH and a suprapubic catheter had the drainage bag lying on the bed beside him instead of hanging below the bladder. The care plan and catheter care checklist directed that the bag and tubing be kept below bladder level for gravity drainage, and an LPN and the DON both stated the bag should be hanging at the side or edge of the bed. The facility did not provide a policy and procedure for SPC care.
A resident with dysphagia, COPD, and severe cognitive deficits was dependent on GT feeding, but staff did not administer the tube feeding timely and the resident was short of the ordered volume. Observations showed the feeding off at one point and later running at 65 ml/hr, while the LPN confirmed the resident received less than the expected amount over 72 hours. The resident also had documented weight loss, and the DON stated staff were expected to follow the MD order and notify the MD when tube feeding totals were off.
A resident with acute osteomyelitis had an order for Cefepime 2 grams IV every 8 hours, but an LPN confirmed a scheduled dose was given late and was not documented as late or reported to the MD. The same resident had a PICC line with an order to measure external catheter length on admission and with dressing changes, but the LPN stated the line was dressed without measuring the catheter length and no admission measurement was documented.
PTSD Not Identified and Addressed: A resident with PTSD was admitted with a documented trauma history, but staff did not consistently know which residents had PTSD or what the diagnosis meant. The resident described specific triggers such as smells and talking about past trauma, while the care plan listed triggers including loud noises, yelling, and nightmares. Interviews showed CNA knowledge gaps, and the DON stated staff should know residents with PTSD to properly manage behavior and avoid re-traumatization.
The facility failed to ensure appropriate diagnosis documentation and side effect monitoring for two residents receiving psychotropic medications. One resident receiving olanzapine had documentation of akathisia on the MAR and was observed with restlessness and tremors, but there was no note showing the MD or psychiatrist was informed. Another resident receiving trazodone and sertraline had a pharmacist warning for possible serotonin syndrome, yet the MAR showed no monitoring for symptoms and staff stated the resident was not being monitored despite tremors, jerking movements, and agitation.
Trash Left Around Kitchen Dumpsters: Surveyors observed food waste and wrappers in a two-foot by two-foot area between two locked dumpsters behind steel fencing. The DM stated the area around the dumpsters should be clean with no debris, and the DOM stated there should not be any trash around the dumpsters. The IDON stated all environments should be sanitized and clean, and the facility policy required trash/dumpster receptacles by the kitchen area to be clean and tidy.
A resident in an LTC facility did not receive prescribed morphine for comfort care before passing due to a failure in obtaining the medication from the contracted pharmacy. The facility did not contact the pharmacy for an emergency delivery, and the available Ativan was not administered. The resident had multiple serious health conditions and was at the end of life. The facility's policy for pharmaceutical services was not effectively utilized.
A resident with chronic osteomyelitis and a foot ulcer did not receive scheduled showers, leading to potential poor hygiene and decreased well-being. Staff failed to document refusals and offer alternative bathing options, contrary to facility protocol.
Failure to Replace Damaged Low Air Loss Mattress
Penalty
Summary
The facility failed to replace a damaged low air loss mattress for Resident 168, who was admitted with congestive heart failure, a prior myocardial infarction, and muscle weakness. His admission assessments showed intact cognition with a BIMS score of 15, and he required supervision or touching assistance for several transfers and position changes. His skin assessment on admission showed no pressure ulcers, and his care plan and physician order both included use of a low air loss mattress for maintenance of skin integrity. On 9/23/2025, Resident 168 told staff that the pump had been removed from his low air loss mattress and that he had been left sleeping on the mattress topper without the pump overnight. He stated he had asked for the mattress to be changed that night, but staff told him they could not do so. When interviewed the next morning, he was observed sitting in his wheelchair and appeared sleepy. The resident stated that the bed had been changed later that morning in about 60 seconds. Staff interviews showed that the mattress problem was known and that the expectation was for the broken mattress to be changed as soon as possible. The CNA stated the mattress seemed underinflated, thin, and uncomfortable, and that the resident complained of not getting a good night's sleep. The LN stated she called maintenance after being told the mattress was malfunctioning, and that night shift staff should have changed the mattress or provided a comfortable alternative. The RNS and IDON both stated that a broken low air loss mattress should be changed ASAP for comfort and skin integrity, and facility policy required a safe, functional, sanitary, and comfortable environment and accommodation of reasonable resident needs, including a comfortable bed or mattress.
Unrepaired Room Damage Affected Resident Environment
Penalty
Summary
The facility failed to repair damage in two residents’ rooms, including a ceiling area in one room and a wall in another room, leaving both areas in an unfinished condition. Resident 10 was admitted with diagnoses including pneumonitis, Parkinson’s disease, and major depressive disorder, and had a BIMS score of 15 indicating intact cognition. During observation, Resident 10 stated that a man had fallen through the ceiling while repairing the roof and that the ceiling had been like that for about a week and a half; the ceiling was observed with a two-foot by two-foot plaster repair that had not been painted, and a person’s handprint was visible next to the repair. Resident 10 stated, “I have to look at that all day.” Resident 168 was admitted with diagnoses including congestive heart failure, myocardial infarction, and muscle weakness, and also had a BIMS score of 15 indicating intact cognition. During observation, the wall by the right side of Resident 168’s bed was seen with a one by two-foot area of gouges in the paint and drywall from collisions with the bed. Resident 168 stated the wall had been like that for a while and that it did not feel homelike and he would like it repaired. The maintenance log for the unit had no entries for either the ceiling damage or the wall damage, and the Director of Maintenance and Interim Director of Nursing stated the damage should have been repaired in a timely manner and was not homelike.
Inaccurate MDS Diagnosis Documentation
Penalty
Summary
The facility failed to accurately complete the MDS for one of 27 residents reviewed for MDS accuracy. Resident 127 was admitted with a primary diagnosis of paranoid schizophrenia, and the record review showed quarterly and annual MDS assessments listing paranoid schizophrenia as an active diagnosis. However, the resident’s available clinical documentation did not support that diagnosis. The most recent geriatric psychiatry note dated 8/11/2025 listed a history of major NCD and psychosis not otherwise specified, but did not list schizophrenia or paranoid schizophrenia, and prior psychiatry notes dating back to 4/1/24 also did not include paranoid schizophrenia. Additional record review showed the discharge note from the San Diego VA Medical Center dated 1/26/23 listed unspecified psychosis with rule out substance-induced vs neurocognitive disorder, and described prior hospitalizations related to psychosis associated with not taking medication or methamphetamine use. Resident 127’s physician orders included olanzapine for paranoid schizophrenia, schizophrenia, and acute psychosis-hearing voices. During interview, LN 32 stated admitting diagnoses were discussed by the IDT and then entered by the MDS nurse, and the IDON stated no documentation was located for Resident 127’s diagnosis of paranoid schizophrenia. The IDON also stated the expectation was that assessments and diagnoses were entered correctly by the MDS nurse and reviewed by the IDT team for accuracy.
Improper Suprapubic Catheter Bag Positioning
Penalty
Summary
The facility failed to appropriately care for a resident's suprapubic catheter for one of three residents reviewed for catheter care. Resident 91 was admitted with diagnoses including benign prostatic hyperplasia and had physician orders for the SPC to be changed as needed when plugged or dislodged once a day. The care plan directed that the suprapubic catheter be connected to gravity drainage, with the catheter bag and tubing positioned below the level of the bladder and away from the entrance room door. During an observation, Resident 91 was lying in bed with a small urine drainage bag next to the resident's right side on the bed. The resident stated the bag drained urine. A skills checklist for Foley/Suprapubic Catheter Care indicated to keep tubing below the level of the bladder. LN 11 stated the SPC bag should not be on top of the bed and should be clipped on the side of the bed and hanging to drain urine. The IDON stated the SPC bag should be hanging down at the edge of the bed to prevent urine from backing up to the bladder. The facility did not provide a policy and procedure regarding care of a resident with SPC.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to follow the MD’s tube feeding orders for one of six residents reviewed, Resident 107, who had a history of COPD and severe cognitive deficits and was dependent on enteral nutrition for dysphagia. On 9/23/25, Resident 107 was observed in bed with the tube feeding turned off. On 9/24/25, the tube feeding was observed running at 65 ml/hr, and the MD order directed continuous GT feeding of a formula at 65 ml/hr for 20 hours, from 2 PM to 10 AM or until the desired volume was reached, to provide 1300 cc and 1950 calories in 24 hours via enteral feeding pump. During interview and record review, LN 21 stated the resident should receive 1300 ml of tube feeding per day and demonstrated that the resident received 3665 ml over 72 hours, while 3900 ml would have been expected over that same period. LN 21 stated the resident was short 235 ml because the tube feeding was not administered timely on 9/23/25, and that the MD should have been notified so adjustments could be made. The resident’s weight record showed a loss from 183 lbs on 3/2/25 to 176 lbs on 9/1/25. The IDON stated staff were expected to follow MD orders, clarify tube feeding totals, and notify the MD when needed, and also stated the resident relied on tube feeding and was at risk for weight loss and malnutrition from not receiving adequate calories.
Late IV Antibiotic Administration and PICC Line Measurement Not Completed
Penalty
Summary
Resident 129 was admitted with diagnoses including acute osteomyelitis of the right ankle and foot and had physician orders for Cefepime HCL 2 grams IV every 8 hours until 10/14/25. During interview, the resident stated that on 9/20/25 the night nurse did not administer the 6 A.M. dose and that the morning shift nurse gave the medication at 10 A.M. instead. The MDS dated 9/10/25 showed a cognitive score of 15, indicating cognition was intact. On concurrent record review, Licensed Nurse 13 confirmed she was assigned to administer the IV antibiotic and that the 6 A.M. dose was given at 2 P.M. on 9/21/25, which she identified as a late dose. She also stated there was no documentation regarding the late administration and the physician was not notified. Resident 129 also had a PICC line, and the physician ordered the external catheter length to be measured upon admission and with each dressing change every day shift every Sunday. During record review and interview, LN 13 stated she changed the PICC dressing but did not measure the catheter length as ordered, and there was no measurement documented on admission. She stated the measurement was important to ensure the catheter was intact and to prevent pulmonary embolism. The Interim DON stated she expected nursing staff to follow physician orders for medication administration and PICC line care.
PTSD Not Identified and Addressed
Penalty
Summary
The facility failed to ensure that one resident with PTSD received care and services in accordance with professional standards when the resident's PTSD was not identified and addressed by healthcare providers. The resident was admitted with diagnoses including PTSD and stated during interview that he was a veteran with PTSD related to an explosion that burned his body and threw him into the ocean. He reported that smells and talking about the experiences were triggers, and that he kept the light and television on because of nightmares. The care plan identified the resident as at risk for re-traumatization related to PTSD and noted triggers including loud noises, yelling, and nightmares. During interviews, CNA 11 stated she was unsure what PTSD meant and was not sure which residents had the diagnosis. CNA 12 stated PTSD meant a resident had something stressful from past experiences, especially military experiences, but was not aware of any residents with PTSD. LN 11 stated that triggers could activate past trauma and that knowing the triggers was important because they were part of the resident's plan of care. The IDON stated all staff should know which residents had PTSD so they could properly treat and manage behavior. The facility's undated PTSD Disorder Management policy stated it was the policy to identify residents with a history of trauma and that all staff would maintain a safe environment and avoid unnecessary actions that may cause re-traumatization.
Psychotropic Medication Monitoring and Diagnosis Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic and antidepressant medications had appropriate diagnoses and were monitored for side effects as recommended by the pharmacist for two residents. The deficiency involved Resident 127 and Resident 16, both of whom were receiving psychotropic medications and had documentation issues related to diagnosis verification and monitoring of medication-related adverse effects. Resident 127 was admitted with a diagnosis of paranoid schizophrenia, and the MDS assessments also documented paranoid schizophrenia as an active diagnosis. However, the most recent geriatric psychiatry note listed a past history of major neurocognitive disorder and psychosis not otherwise specified, and earlier hospital records reflected psychosis with rule out substance-induced versus neurocognitive disorder, without a diagnosis of paranoid schizophrenia. The resident had orders for olanzapine, including a PRN order for psychosis, a bedtime order for schizophrenia, and a morning order for paranoid schizophrenia. Nursing documentation began marking akathisia on the medication record starting on the night shift of August 23 and continuing each shift thereafter, and the resident was observed frequently moving from sitting to standing, stating he could not seem to be still and that the feeling had started in the last three months. The record review found no nursing progress note documenting that the physician or psychiatrist was informed of the new symptom of akathisia. Resident 16 had diagnoses including a history of major depressive disorder and was documented on the MDS as rarely or never understood with severe cognitive deficits. The medication record reconciliation identified a pharmacist recommendation warning that trazodone and sertraline coadministration may lead to serotonin syndrome and listed symptoms to observe for, with the physician response noted as “will obs.” The MAR did not show that serotonin syndrome symptoms were being observed or monitored during the months reviewed. Resident 16 had orders for trazodone at bedtime for depression and sertraline daily for depression, and during observation was seen mumbling to self, unable to carry on a conversation, with hand tremors, jerking legs, and repeated attempts to stand from the wheelchair. Staff stated the tremors were normal for him, that he was a fall risk, and that he was not being monitored for serotonin syndrome. The facility was unable to provide a policy and procedure for psychotropic medication use and/or monitoring.
Trash Left Around Kitchen Dumpsters
Penalty
Summary
The facility failed to clean up trash around the kitchen dumpsters. On 9/24/2025 at 9:08 A.M., surveyors observed three facility dumpsters locked behind steel fencing and saw a pinkish-orange substance appearing to be food waste and food wrappers in a two foot by two-foot area between two dumpsters. During the observation, the Dietary Manager stated the area around the dumpsters should be clean with no food waste or debris between dumpsters and that such debris could attract rodents and other pests. Later that day, the Director of Maintenance stated that after a dumpster is emptied, maintenance workers move the dumpsters, sweep the area, and power wash it, and that there should not be any trash around the dumpsters. On 9/26/2025, the Interim Director of Nursing stated that all environments should be sanitized and clean and that the importance of this was to prevent infestations from rodents and other pests and for infection control. The facility policy titled Physical Environment, dated 3/2025, stated the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, and that trash/dumpster receptacles must be clean and tidy by the kitchen area.
Failure to Administer Comfort Care Medication
Penalty
Summary
The facility failed to obtain and administer an ordered medication for a resident who was receiving comfort care at the end of life. The resident, who had multiple serious health conditions including acute kidney failure, pneumonia, COPD, heart failure, Parkinson's disease, and Alzheimer's disease, was prescribed morphine for pain relief and comfort. Despite the physician's order, the morphine was not administered before the resident's passing. The Assistant Director of Nursing (ADON) confirmed that there was no documentation of the pharmacy being contacted for an emergency delivery of the medication, and the Director of Nursing (DON) acknowledged that the standard of care was not met as the medication was not given. The contracted pharmacy did not receive a complete prescription order, as it lacked a physician's signature and quantity, and was not alerted by the facility of the urgent need for the medication. The pharmacy owner stated that the order was received via fax without indication of urgency and that no phone call was made by the facility to expedite the process. Additionally, Ativan, which was available in the emergency kit, was not administered to the resident. The facility's policy required regular and reliable pharmaceutical services, including emergency deliveries, but these were not utilized effectively in this case.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, which could lead to poor personal hygiene and decreased psycho-social well-being. The resident, who was admitted with chronic osteomyelitis and a foot ulcer, was alert and oriented with moderate cognitive impairment. The resident was scheduled to receive showers twice a week, but records showed that from November to February, the resident was often only given sponge baths or no documented showers at all. There was also no documentation of the resident refusing showers during this period. Interviews with staff, including the Director of Staff Development, Licensed Nurse, and Certified Nurse Assistant, revealed that the protocol for handling shower refusals was not followed. The staff should have documented refusals and offered alternative bathing options, but this was not consistently done. The Assistant Director of Nursing confirmed that the resident should have received showers twice a week and that refusals should have been documented and communicated to the Licensed Nurse. The facility's policy on providing ADL/shower to residents was requested but not available.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Villas Post Acute | 0.7 mi | — | 0 | 0 |
| La Paloma Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Vista View Post Acute | 1.3 mi | ★★★★★ | 1 | 0 |
| Bayshire Carlsbad | 2.6 mi | ★★★★★ | 1 | 0 |
| Santa Fe Post-acute | 3.1 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.