Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Post Acute during CMS and state inspections, most recent first.
Surveyors observed a medication error rate of 13.79% due to multiple failures, including a resident not receiving a scheduled mouthwash dose because it was unavailable, a nurse incorrectly priming an insulin pen before injection, a resident receiving metformin before meals instead of with meals as ordered, and a nurse holding blood pressure medications outside of the prescribed parameters. These errors involved several residents and staff, and were inconsistent with physician orders, manufacturer instructions, and facility policy.
Surveyors found that the facility did not maintain clean and safe conditions for food storage and preparation, with dirty and damaged kitchen floors, exposed wall gaps, buildup of food residue, and improper food labeling and rotation. Staff interviews and record reviews confirmed that cleaning schedules were not followed, maintenance requests were not documented, and expired or unlabeled food was present, increasing the risk of food contamination for residents.
Nursing staff did not follow infection control protocols during medication administration, including failing to perform hand hygiene after touching contaminated surfaces, handling medication capsules with bare hands, and not wearing required gowns during high-contact care for residents with feeding tubes. These lapses were observed during medication passes and were acknowledged by the staff involved.
Nursing staff did not consistently verify gastrostomy tube placement before administering medications to three residents, as required by facility policy. Staff either omitted the placement check or only checked residual volume, and interviews confirmed this was not routinely done. The DON stated that both tube placement and residual volume should be checked before medication administration.
Discontinued and unused controlled medications, including morphine, lacosamide, and lorazepam, remained in a medication cart for several days after being discontinued or after a resident left, despite facility policy requiring prompt removal and destruction by the DON. Nursing staff confirmed the medications were not removed as required, and controlled drug records indicated the medications should have been addressed earlier.
A resident with a history of falls and diabetes was not provided necessary meal assistance, leaving them unable to finish dinner. Despite needing help with meal setup and positioning, staff did not reposition the resident or assist with the meal tray, leaving the resident uncomfortable and unable to reach or open food items. This oversight was confirmed through observations and staff interviews, highlighting a failure to follow the resident's care plan.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 13.79%, exceeding the acceptable threshold of 5%, as four medication errors were observed out of 29 opportunities during medication administration for four residents. One resident did not receive a scheduled dose of chlorhexidine mouthwash because the medication was not available in the facility, despite a physician's order for its administration three times daily. The medication administration record and progress notes confirmed the missed dose was due to a pending supply, which is inconsistent with the facility's policy requiring timely access to prescribed medications. Another resident received insulin via a Humalog Kwikpen, but the nurse did not follow the manufacturer's instructions for priming the pen, using two needles and failing to prime the pen correctly before administration. The nurse later acknowledged the error and confirmed the correct procedure was not followed, which is also outlined in the facility's medication administration policy. Additionally, a resident prescribed metformin to be given with meals received the medication well before the meal was served, contrary to the physician's order and the drug's package insert, which states it should be administered with meals to reduce gastrointestinal side effects. The nurse administering the medication confirmed the timing varied and was not always coordinated with meal service. A further error occurred when a nurse held both amlodipine and lisinopril for a resident with a blood pressure reading of 108/80, despite the physician's order specifying to hold amlodipine only if the systolic blood pressure was less than 100. The nurse admitted to holding the medication based on a general practice rather than the specific order, and the Director of Nursing confirmed the correct hold parameter. These incidents demonstrate failures to administer medications as prescribed, follow manufacturer instructions, and adhere to facility policies.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain a clean and safe environment for food storage and preparation, as evidenced by multiple observations of unsanitary conditions in the kitchen. Surveyors noted that floor drains were not clean, kitchen tile floors were dirty and in disrepair, and there were gaps and exposed wood in the kitchen walls, particularly around the dishwashing area. The backsplash behind the sink had a buildup of food and a black substance, and missing grout and loose tiles were observed, which allowed for the accumulation of debris and pooling water. These conditions were confirmed by interviews with the Certified Dietary Manager and the Janitor, who acknowledged that the lack of maintenance made deep cleaning difficult and could lead to the collection of food, dirt, and mold. Additionally, the facility did not adhere to its own policies regarding food labeling and storage. Frozen meats in the freezer were not labeled with the date received, date placed in the freezer, use by date, or expiration date. Produce, such as onions, was not rotated according to the First In-First Out (FIFO) method, and new stock was mixed with old stock without proper labeling. Other food items, such as raisins, were stored in containers without open, use by, or expiration dates, and some food in the refrigerator was found to be expired. Staff interviews confirmed that these practices did not comply with facility policy and increased the risk of food contamination. Record reviews revealed that the facility lacked documentation of a kitchen deep cleaning and did not maintain a cleaning schedule as required by policy. Maintenance logs did not reflect requests for necessary repairs to the kitchen's tile, flooring, and walls. The facility's policies and the 2022 Federal Food Code require that floors and wall junctures be smooth, easily cleanable, and properly sealed to prevent contamination, but these standards were not met. These failures had the potential to result in food contamination for the 69 residents residing in the facility.
Failure to Follow Infection Control and Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
Nursing staff failed to adhere to proper infection control practices during medication administration for multiple residents. One RN was observed preparing and administering medications to a resident after touching potentially contaminated surfaces, such as a wheelchair and a bed remote control cable that had been on the floor, without changing gloves or performing hand hygiene. The RN acknowledged that these surfaces were potentially contaminated and that she should have changed gloves and performed hand hygiene before proceeding with medication administration. Another nurse, an LVN, was observed opening medication capsules with bare hands, without donning gloves, and admitted she should have worn gloves. The facility's policy requires staff to follow infection control procedures, including handwashing and glove use, during medication administration. Additionally, the same LVN failed to follow Enhanced Barrier Precautions (EBP) as outlined in the facility's policy when administering medications via gastrostomy tube to two residents who were roommates. Although the LVN wore a mask and gloves, she did not wear a protective gown as required for high-contact resident care activities involving device care or use, such as feeding tubes. The facility's EBP policy and posted signage specified that staff must wear gloves and a gown for such activities. The LVN was unsure about the requirement for gown use during medication administration via G-tube, and the DON confirmed that full PPE, including a gown, is required for these procedures.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
Nursing staff failed to follow facility policy and procedures regarding the administration of medications through gastrostomy tubes for three residents. Specifically, staff did not consistently verify tube placement prior to administering medications. During medication administration observations, one LVN checked residual volume but did not confirm tube placement for two residents, while an RN neither checked tube placement nor residual volume for another resident. Staff interviews revealed that checking tube placement before medication administration was not routinely performed, and one nurse admitted to forgetting the procedure due to nervousness. The facility's policy requires staff to verify the placement of feeding tubes before administering medications. The Director of Nursing confirmed that the expected practice is to check tube placement by injecting air and listening with a stethoscope, as well as checking residual volume. The observed failures to follow these procedures occurred during medication administration for residents who were receiving medications via gastrostomy tubes, as documented in the facility's policy and procedures.
Failure to Promptly Remove Discontinued Controlled Medications from Medication Cart
Penalty
Summary
The facility failed to promptly remove discontinued and unused controlled medications from a medication cart, as observed during inspections with nursing staff. Two opened bottles of morphine for one resident were found in the locked compartment of the cart, with their controlled drug records indicating a zero count, yet both bottles still contained leftover medication. These bottles had not been counted during shift changes and remained in the cart for 7 and 13 days after being zeroed out on the count sheets. Additionally, two blister cards of lacosamide, a controlled medication, belonging to another resident who had left the facility 15 days prior, were still present in the cart. A bottle of lorazepam, discontinued 14 days earlier for a third resident, was also found in the cart. Nursing staff confirmed that these medications were supposed to be removed and given to the Director of Nursing for destruction immediately after discontinuation or when a resident left the facility. The facility's policy required discontinued or empty controlled medication containers to be discarded with two nurses or given to the DON for proper destruction, and to remain in the narcotic count until discarded. However, the medications remained in the cart well beyond the discontinuation dates, contrary to policy and procedure.
Failure to Assist Resident with Meal Setup and Positioning
Penalty
Summary
The facility failed to provide necessary meal assistance to a resident, leading to the resident's inability to finish dinner. The resident, who was admitted with a diagnosis of fall, lumbar vertebra fracture, rib fractures, muscle weakness, and diabetes, required assistance with meal setup as per their care plan. Despite having a cognitive status indicating they could make themselves understood and feed themselves with setup assistance, the staff did not reposition the resident higher in bed or assist in setting up the meal tray for 30 minutes during dinner. This left the resident in an uncomfortable position, unable to reach or open food items, which could potentially lead to weight loss and low blood sugar. Observations and interviews revealed that the resident was often left flat on the bed with the bed controls and bedside table out of reach. During an observation, the resident was found lying flat with the meal tray parallel to the bed, unable to reach or open food items. The dietary manager and staff confirmed that the resident required assistance with opening food items and repositioning for comfort during meals. Despite these needs being documented, the staff did not follow the instructions, leaving the resident unable to eat comfortably. The resident expressed discomfort and inability to eat due to their position in bed, highlighting the staff's failure to adhere to the care plan requirements.
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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 Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayward Gardens Post Acute | 1.1 mi | ★★★★★ | 13 | 0 |
| Hayward Hills Health Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Sage Post Acute | 1.1 mi | ★★★★★ | 1 | 0 |
| Canyon Creek Post-acute | 1.2 mi | ★★★★★ | 2 | 0 |
| Baywood Court Health Center | 1.7 mi | ★★★★★ | 0 | 0 |
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