Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Pacifica Center during CMS and state inspections, most recent first.
Dietary staff were unable to correctly prepare sanitizer solutions, failed to wear gloves during table sanitization, and did not properly test dish sanitization, as confirmed by interviews and observations. These failures were inconsistent with facility protocols and manufacturer instructions, and were acknowledged by the Registered Dietitian and Director of Dietary Services.
Three cutting boards in the kitchen were found with deep indentations and rough surfaces, making them difficult to clean and sanitize. The Director of Dietary Services acknowledged that the boards should have smooth surfaces to prevent microorganism growth, and their condition did not meet professional food service safety standards.
A resident with cognitive impairment, legal blindness, and an upper limb amputation was not offered a smoking apron during a supervised smoking break, despite care plan and facility policy requirements. Staff acknowledged the omission and the importance of the apron in preventing accidental burns or injuries.
A resident with schizophrenia received long-acting injectable antipsychotic medication earlier than prescribed, contrary to physician orders and manufacturer guidelines, with no supporting clinical evidence for the altered schedule. Additionally, an Oral Emergency Kit was found to have an incorrect expiration date on its label, not matching the actual expiration of its contents, as confirmed by an LVN. Facility policies regarding medication administration and emergency kit labeling were not followed.
Four unit dose vials of ipratropium/albuterol inhalation solution belonging to a resident were found stored outside the manufacturer's protective foil pouch, contrary to manufacturer instructions and facility policy. An LVN confirmed the vials should have remained in the pouch to protect them from light, creating the potential for the resident to receive ineffective medication therapy.
A resident with severe protein-calorie malnutrition and diabetes, who was cognitively intact, requested cottage cheese as a bedtime snack but was only provided fruit cups. Despite documentation of this preference in the nutritional assessment and no clinical contraindications, the dietary staff did not honor the request, and all snack labels listed only fruit. Both the DM and RD confirmed the resident's preference should have been accommodated according to facility policy.
A Laundry Aide did not properly clean the lint trap in a dryer, resulting in a thick accumulation of lint. The cleaning log was inaccurately completed, with entries signed ahead of scheduled times rather than after the task was performed. Facility policy requires lint removal every two hours, but this was not followed, creating a potential fire hazard.
A resident with schizophrenia and moderate cognitive impairment was found with contraband (a metal fork) in their room. Although staff retrieved the item and counseled the resident, the resident's representative was not notified of the incident, contrary to facility policy. Multiple staff members acknowledged the oversight, and documentation confirmed the lack of notification.
A resident with schizophrenia and moderate cognitive impairment was found with a metal fork, considered contraband, under the mattress. Although staff discussed new interventions such as using plastic utensils and searching the resident for contraband after meals, these were not added to the care plan, and some staff were unaware of the need for such measures. The care plan was not revised as required following the incident.
A resident with schizoaffective disorder and osteoarthritis was not treated with dignity and respect during a smoke break when a Mental Health Worker (MHW) kicked a dropped cigarette out of reach, causing the resident to fall from the wheelchair. The MHW did not assist the resident back into the wheelchair or offer another cigarette, leading to the resident's agitation. Another staff member intervened to help the resident, but the MHW's actions were confirmed as inappropriate through security footage, resulting in the MHW's termination.
A resident with schizoaffective disorder and osteoarthritis was neglected when a Mental Health Worker left them on the ground after a fall during a smoke break. The incident was observed by an LVN and reported to the DON, but the report to CDPH was delayed beyond the required two-hour timeframe, violating facility policy.
The facility failed to implement an effective infection surveillance system for suspected scabies among six residents. A resident reported having scabies for a month before treatment began, and other residents were treated prophylactically. The Infection Preventionist and Director of Nursing were unaware of a specific surveillance process, and no tracing was conducted to track potential exposure. The facility's policies on infection prevention and control were not effectively implemented, leading to a delay in care and potential spread of infection.
The facility failed to ensure the designated Infection Preventionist (IP) completed the required specialized training for certification. During an unannounced visit, it was found that the IP was not certified, and there was confusion about oversight responsibilities. The facility's policies require the IP to be qualified by education, training, experience, or certification, and to have completed specialized training, which was not met.
A resident consumed cannabis-infused candy brought in by a staff member, leading to feelings of nausea and discomfort. The candy was mixed with regular candies given as rewards, and the incident was not documented or reported to the state. The facility lacked a policy on outside candy and did not follow protocols for drug testing or reporting changes in condition.
The facility failed to report an altercation between two residents to the CDPH within the required two-hour timeframe. The incident involved one resident spitting at and shoving another, which was not reported immediately by the staff who witnessed it. The delay in reporting violated the facility's abuse protocol.
Dietary Staff Lacked Proper Sanitization Procedures and Training
Penalty
Summary
The facility failed to ensure that dietary staff were able to safely and effectively carry out food and nutrition services. Two dietary staff members were unable to demonstrate the correct concentration for the red bucket sanitizer solution, with one staff member preparing a solution with only half the required water and another preparing a solution with less than the required one gallon. The Registered Dietitian confirmed the correct ratio and stated that improper concentration could result in foodborne illness. Additionally, the facility's Red Sanitizer Bucket Log Checklist and FDA Food Code were reviewed, both specifying the importance of correct sanitizer concentration. One dietary staff member did not wear gloves while sanitizing the food preparation table, admitting to forgetting and acknowledging the need for gloves for safety and contamination prevention. Furthermore, four dietary staff members could not demonstrate the proper procedure for testing dish sanitization, as they only tested the water compartment rather than also testing the surface of cleaned dishes, contrary to the dish machine owner's manual. The Director of Dietary Services confirmed the correct procedure and was unable to provide a written policy supporting the staff's method.
Unsanitary Cutting Boards Found in Kitchen
Penalty
Summary
Surveyors observed that three cutting boards in the facility's kitchen, identified as brown, green, and red and each measuring 24 inches by 18 inches, had deep indentations and rough surfaces. During a concurrent interview, the Director of Dietary Services confirmed that the cutting boards should have smooth surfaces to prevent the growth of microorganisms in the grooves. The presence of these damaged cutting boards was not in accordance with professional standards for food service safety, as outlined in the U.S. FDA Food Code 2022, which states that scratched and scored cutting surfaces may be difficult to clean and sanitize, potentially allowing pathogenic microorganisms to accumulate. No specific residents or their medical histories were mentioned in relation to this deficiency.
Failure to Provide Smoking Apron During Supervised Smoking Break
Penalty
Summary
A deficiency occurred when the facility failed to provide a safe, accident-free environment for a resident during a smoking break. The resident in question had multiple diagnoses, including schizoaffective disorder, legal blindness, and an acquired absence of an upper limb below the elbow. The resident's Minimum Data Set assessment indicated cognitive impairment, and the resident's smoking assessment and care plan both specified the need for a smoking apron to be offered during smoking breaks to reduce the risk of injury. On the observed date, a Mental Health Counselor lit a cigarette for the resident on the smoking patio, but did not offer or provide a smoking apron, contrary to the resident's care plan and facility policy. During an interview, the staff member acknowledged that the apron should have been offered and recognized its role in preventing accidental burns or injuries. Facility policy also indicated that smoking aprons should be used when appropriate to ensure resident safety.
Failure to Administer Medications as Prescribed and Inaccurate Emergency Kit Labeling
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed and used appropriately to meet the needs of the residents. Specifically, a resident with schizophrenia was prescribed two long-acting injectable antipsychotic medications, Invega Sustenna and Haldol Decanoate, with orders for Invega Sustenna to be administered every 28 days. However, the medication administration record showed that Invega Sustenna was given earlier than prescribed: one dose was administered 21 days after the previous dose, and another was given 22 days after the prior dose. Interviews with the pharmacist, DON, and Medical Director confirmed that the medication was administered sooner than recommended by both the physician's order and the manufacturer's prescribing information. There was no physician order to alter the dosing interval, and no clinical evidence supported the practice of staggering the two antipsychotics two weeks apart. Additionally, during an inspection of the Emergency Kits, it was observed that the expiration date written on the outside of the Oral Emergency Kit did not match the actual expiration date of the medication inside. The kit was labeled with an expiration date of July, but it contained doxycycline tablets that expired in June. This discrepancy was confirmed by a licensed vocational nurse, who acknowledged that the expiration date on the outside of the kit was not correct. The facility's policies required medications and treatments to be administered as prescribed and for Emergency Kits to be inventoried monthly, with the earliest expiring medication's date noted on the outside of the kit. These policies were not followed, resulting in the administration of medication outside the prescribed schedule and inaccurate labeling of emergency medication expiration dates.
Improper Storage of Light-Sensitive Medication
Penalty
Summary
During an inspection of Medication Cart A at the Southside Nursing Station, four unit dose vials of ipratropium/albuterol inhalation solution, prescribed for one resident, were found stored outside of their original manufacturer's foil pouch. This storage practice was not in accordance with the manufacturer's instructions, which specify that the vials must be protected from light by remaining in the foil pouch until use. A licensed vocational nurse confirmed that the vials should have been kept in the pouch, and the facility's own policy also requires medications to be stored according to manufacturer recommendations. The improper storage had the potential to result in the resident receiving ineffective medication therapy.
Failure to Honor Resident Food Preference for Snack
Penalty
Summary
The facility failed to honor a resident's stated food preference, resulting in the resident not receiving her requested snack of cottage cheese. Despite the resident informing the dietitian of her preference for cottage cheese as a bedtime snack, she was only provided with fruit cups. Review of the resident's nutritional assessment and care plan confirmed that cottage cheese was listed as a food request, but all snack labels indicated only soft canned fruit. Both the Dietary Manager and Registered Dietitian acknowledged that there were no contraindications to providing cottage cheese and that the resident's preference should have been accommodated. The resident involved had a diagnosis of severe protein-calorie malnutrition and type 2 diabetes mellitus without complications, and was assessed as having intact cognitive function. The care plan and diet order supported the provision of a consistent carbohydrate diet with regular texture, and there was no clinical reason to deny the requested snack. Facility policy also required staff to accommodate resident food preferences and document them in the care plan, but this was not followed in the resident's case.
Failure to Clean Dryer Lint Trap as Required
Penalty
Summary
The facility failed to provide a safe environment when the Laundry Aide (LA) did not properly clean the lint trap in Dryer #3, resulting in a thick accumulation of lint. During an observation and interview in the laundry room, the LA stated that she cleaned the dryer lint trap every two hours, as required by facility policy. However, upon inspection, a thick layer of lint was found covering the entire trap. A review of the Laundry Lint Cleaning Log revealed that entries were signed ahead of the scheduled cleaning times, rather than after the task was completed, indicating inaccurate documentation of the cleaning process. Further interviews with the LA confirmed that the log should only be signed after the lint was actually removed, and the LA acknowledged that the amount of lint present could become a fire hazard if not addressed. The Housekeeping Supervisor also confirmed that the LA should have followed the policy requiring lint removal every two hours. The facility's policy and procedure, dated March 8, 2013, specifies that all lint must be removed from dryers every two hours and at the end of each shift.
Failure to Notify Resident's Representative After Contraband Incident
Penalty
Summary
The facility failed to notify a resident's representative after an incident involving contraband was discovered in the resident's room. The resident, who had a diagnosis of unspecified schizophrenia and moderate cognitive impairment, was found with a metal fork, considered contraband per unit policy. Staff retrieved the item and counseled the resident, but there was no documentation that the resident's representative was informed of the incident. Multiple staff members, including two program counselors and an LVN, acknowledged during interviews that they did not notify the representative, each assuming another staff member would do so or not realizing the incident was new. Facility policy required prompt notification of a resident's representative in the event of changes in the resident's condition or status, including significant changes in mental or psychosocial status. Despite this, the incident was not communicated to the representative, as confirmed by the Director of Nursing. The lack of notification was documented in the resident's progress notes and corroborated by staff interviews.
Failure to Revise Care Plan After Contraband Incident
Penalty
Summary
The facility failed to revise the care plan and implement appropriate interventions after a resident with a diagnosis of unspecified schizophrenia and moderate cognitive impairment was found with contraband, specifically a metal fork, under his mattress. Staff discovered the fork during a routine room check and removed it, subsequently informing the resident of the unit rules regarding unauthorized items. The incident was documented, and the assigned Program Counselor and other staff were notified. However, although there was discussion among staff about initiating new interventions, such as checking the resident for contraband after meals, these interventions were not added to the resident's care plan. The care plan, which was updated to reflect the incident of inappropriate behavior, did not include any new behavioral interventions to prevent the resident from taking contraband from the dining room. Interviews with staff, including the Program Counselor and the DON, confirmed that no new interventions were added to the care plan following the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition dictate. Additionally, some staff members were unaware of the need to search the resident for contraband after meals, indicating a lack of communication and implementation of appropriate interventions.
Resident Dignity and Respect Violation by MHW
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by an incident involving a Mental Health Worker (MHW 1) and a resident with schizoaffective disorder and osteoarthritis of the knee. During a smoke break, the resident accidentally dropped a cigarette, and MHW 1 kicked it out of reach, causing the resident to fall from his wheelchair. MHW 1 did not assist the resident back into the wheelchair or offer another cigarette, leading to the resident becoming angry and agitated. Interviews and record reviews revealed that MHW 1's actions were unprofessional and did not align with the facility's expectations for staff to assist residents with tasks they could not perform themselves. Another staff member, MHW 2, intervened by helping the resident back into the wheelchair and retrieving the cigarette, which temporarily settled the situation. However, MHW 1's continued antagonistic behavior, including kicking another cigarette away, further escalated the resident's agitation. The Director of Nursing (DON) and other staff members reviewed security footage, confirming MHW 1's inappropriate conduct. The footage showed MHW 1 antagonizing the resident and failing to provide necessary assistance, which violated the resident's rights to dignity and respect. The incident was reported to the DON, who took immediate action by sending MHW 1 home pending investigation, ultimately leading to the termination of MHW 1's employment.
Failure to Timely Report Resident Neglect
Penalty
Summary
The facility failed to report an incident of neglect involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved a resident with schizoaffective disorder and osteoarthritis of the knee, who was left on the ground by a Mental Health Worker (MHW) after falling from his wheelchair during a smoke break. The MHW had antagonized the resident by withholding a cigarette and later kicked a cigarette away, causing the resident to fall. Another staff member assisted the resident back into his wheelchair, but the neglect was not reported promptly. The Licensed Vocational Nurse (LVN) observed the incident on security footage and reported it to the Director of Nursing (DON) at approximately 8:50 p.m. The Director of Staff Development (DSD) was informed at 9:30 p.m., but the report to CDPH was not made until 11:20 p.m., exceeding the two-hour reporting requirement. The facility's policy mandates that all suspected abuse or neglect be reported within two hours, but this was not adhered to, resulting in a delay in notifying the appropriate authorities.
Failure in Infection Surveillance for Scabies
Penalty
Summary
The facility failed to develop and implement an ongoing infection surveillance monitoring system for suspected scabies among six residents. During an unannounced visit, it was observed that Resident 1 had a rash on his lower extremities and reported having scabies for a month, with treatment only recently initiated. The facility's records indicated that Resident 1 had been monitored for redness and rash since early August, but no new orders were given until the end of the month when scabies treatment was ordered. Other residents, including Residents 2, 3, 4, 5, and 6, were also monitored for rashes and treated prophylactically for scabies, although not all exhibited symptoms. The designated Infection Preventionist (IP) and the Director of Nursing (DON) were not aware of a specific surveillance process for scabies, and no tracing or surveillance was conducted to track other residents who might have been affected. The IP only became aware of the scabies issue on September 2, 2024, and initiated contact isolation at that time. The DON was informed on September 3, 2024, and stated that the residents were placed on contact isolation, but there was no system in place to verify, assess, monitor, or track if other residents were affected by scabies. The facility's policies on infection prevention and control, as well as surveillance of infections, were not effectively implemented. The Administrator admitted to not being aware of a current surveillance process for scabies and acknowledged the need for a system to track residents who develop rashes and evaluate for possible scabies. The lack of a structured surveillance program led to a delay in care and treatment, with potential for the spread of infection throughout the facility.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training for the IP certification program. During an unannounced visit, it was revealed through interviews and record reviews that the designated IP was not certified at the time of the survey. The IP herself confirmed that she did not have the certification, and the Director of Nursing (DON) acknowledged that the IP was not certified but believed that certification was not necessary if the IP was in the process of obtaining it. Further interviews with the DON and the Administrator (ADM) revealed a lack of oversight and clarity regarding the IP's certification status. The DON was not overseeing the IP and was unaware of who was responsible for this oversight. The ADM stated that both he and the DON were overseeing the IP, who was still waiting to complete her certification class. The facility's job description for the IP position and its policy documents indicated that the IP must be qualified by education, training, experience, or certification and must have completed specialized training in infection prevention and control, which was not the case at the time of the survey.
Resident Consumes Cannabis-Infused Candy Due to Lack of Policy
Penalty
Summary
The facility failed to prevent a resident from consuming cannabis-infused candy, which was brought into the facility by a staff member. The incident involved Resident A, who was given the candy as a reward for participating in group activities. The candy was mixed with regular candies donated by staff, and Resident A reported feeling unwell after consuming it. The label on the candy package indicated it contained cannabis, and Resident A had no prior history of drug use. Interviews with staff revealed that there was no policy regarding the introduction of outside candy into the facility. The Program Counselor and Assistant Program Director confirmed that the cannabis-infused candy was inadvertently brought in by a counselor who was unaware of its contents. Despite Resident A's report of feeling nauseous and sweaty, no immediate medical evaluation was conducted, and there was no documentation of the incident in Resident A's medical record. The Director of Nursing acknowledged that the incident was not reported to the state, as required by the facility's policy on unusual occurrences. Although Resident A's vital signs were monitored, there was no formal protocol in place for handling residents under the influence of illegal substances. The facility's policies on drug testing and reporting changes in condition were not followed, as there was no documentation or incident report completed for Resident A.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of physical abuse between two residents to the California Department of Public Health (CDPH) within the required timeframe. The incident occurred on July 13, 2023, when Resident A and Resident B were involved in an altercation. Resident B spit at Resident A's face and shoved him after being told to stop spitting on the floor. The altercation was witnessed by another resident and a Mental Health Worker (MHW 1), who intervened but did not report the incident immediately. The Director of Nursing (DON) was informed of the incident the following morning, on July 14, 2023, but the report to the state agency was delayed beyond the mandated two-hour window. Interviews with the involved residents and staff revealed that the incident was not documented or reported promptly. Resident A and Resident B both confirmed the altercation, with Resident B stating that he reported the incident to MHW 1 on the night it occurred. However, MHW 1 admitted to getting busy and not reporting the incident to the Charge Nurse until later that night. The Licensed Vocational Nurse (LVN 1) also confirmed that she was not aware of the full details of the altercation until the following morning. The facility's policy requires that all abuse incidents be reported to the state agency within two hours, which was not adhered to in this case. The facility's failure to report the incident immediately resulted in a delay in the implementation of appropriate actions and protections for the residents involved. The DON acknowledged that the incident was not reported within the required timeframe and that this was a violation of the facility's abuse protocol. The facility's policy on abuse reporting clearly states that any suspected or known instances of abuse must be reported by telephone immediately or as soon as practically possible, which was not followed in this instance.
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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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Nursing homes near Jurupa Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Pacifica Convalescent Hospital | 0 mi | ★★★★★ | 0 | 0 |
| Jurupa Hills Post Acute | 0.5 mi | ★★★★★ | 7 | 0 |
| Riverside Behavioral Healthcare Center | 2.6 mi | ★★★★★ | 15 | 0 |
| Community Care On Palm | 2.7 mi | ★★★★★ | 15 | 0 |
| The Grove Care And Wellness | 3.2 mi | ★★★★★ | 2 | 0 |
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