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 View Post Acute during CMS and state inspections, most recent first.
A resident with hemiplegia following a stroke, who was his own responsible party and had previously declined COVID-19 and influenza vaccines, was given both vaccines via IM injection after admission without signing any consent forms. The resident reported being told he had to receive the vaccines and was unaware he could refuse. The IP confirmed there was no documented consent and that the state immunization registry showed no prior doses, while the DON acknowledged that residents have the right to refuse treatment. Facility policies required informed consent and resident participation in treatment decisions, including the right to accept or refuse interventions.
A resident with depression and bipolar disorder, who was alert and oriented, experienced a violation of her rights when a CNA entered her room without permission, searched her drawers for diapers, and used inappropriate language when confronted. The incident was witnessed and reported by staff, and it was confirmed that the CNA was not assigned to the resident and failed to follow facility policy on resident dignity and privacy.
A resident with COPD was transferred to a hospital, but staff did not notify or confirm bed hold status with the family representative, nor was this action documented. Multiple staff interviews confirmed the required notification and documentation were not completed, resulting in confusion for the family about bed hold payment.
Surveyors found that window blinds in five resident rooms were missing multiple slats, creating large gaps that exposed residents to public view and increased heat in the rooms. Staff interviews revealed that some CNAs and RNs either did not notice or failed to report the broken blinds, and the Maintenance Director had not received recent requests for repairs. The facility's process for reporting and addressing maintenance issues was not consistently followed, resulting in the deficiency.
A resident with a history of hemiplegia and moderate cognitive impairment received new diagnoses of depression and bipolar disorder, but the facility did not resubmit a Level II PASARR as required by policy. Interviews with the ADON, SSD, and DON confirmed that a new PASARR should have been completed and submitted after the new mental health diagnoses were added.
A resident with a history of schizoaffective disorder, anxiety, and depression was readmitted and required a Level II PASARR evaluation, but the facility failed to resubmit the necessary Level I screening after being unresponsive to state communication attempts. Facility leadership confirmed the screening should have been resubmitted when notified by the state.
The facility did not post the actual hours worked by RNs, LPNs/LVNs, and CNAs for all reviewed shifts, as required by policy. Staffing records for several days lacked this information, and staff interviews confirmed that postings were sometimes forgotten or not updated, impacting all residents.
A resident with spinal stenosis and discogenic pain was not offered a choice regarding a shower and was transferred by two CNAs without her consent, resulting in incontinence and emotional distress. The resident, who was alert and oriented, reported feeling upset as staff argued during the transfer. Facility policy requires resident choice and informed consent for care, but this was not followed during the incident.
A resident with spinal stenosis and discogenic pain was left exposed and without privacy during a transfer to a shower chair by two CNAs, as the privacy curtain was not used. The incident was witnessed by a cognitively intact roommate and confirmed by the resident, who reported distress during the event. The facility's policy on resident rights was not followed.
A facility failed to ensure that its licensed nurses had the necessary competencies and training for Central Venous Catheter (CVC) care, affecting a resident with End Stage Renal Disease. Several nurses documented incorrect assessments, such as the presence of bruit and trill, which are not applicable to CVC lines. The Director of Nursing acknowledged the deficiency, and the facility lacked a policy for CVC care and training.
Vaccinations Administered Without Informed Consent
Penalty
Summary
The facility failed to honor a resident's right to informed consent and self-determination when administering vaccinations. Resident 1, who was admitted with hemiplegia following a cerebral infarction and was documented as his own responsible party, reported that after admission he was given COVID-19 and influenza vaccines via intramuscular injection. He stated that prior to admission he had never received these vaccines by personal preference and that facility staff told him he had to receive them, and he did not know he could refuse. Interview and record review confirmed that the vaccines were administered on 1/8/26. During a concurrent interview and record review, the Infection Preventionist confirmed that Resident 1 did not sign any consent forms prior to receiving the COVID-19 and influenza vaccines and that the California Immunization Registry showed no prior history of these vaccines for the resident. The Infection Preventionist stated that consents were required from residents or their representatives before administering any vaccines. The DON stated it was her expectation that consents be obtained and acknowledged that residents have the right to refuse vaccines. Facility policies on Informed Consent and Resident Rights indicated that healthcare professionals must provide pertinent information to allow residents or their representatives to accept or refuse proposed treatments, and that residents have the right to be informed of and participate in their treatment, including the right to request, refuse, and discontinue treatment.
Failure to Honor Resident Dignity and Privacy
Penalty
Summary
A certified nursing assistant (CNA) entered the room of a resident with diagnoses including depression and bipolar disorder, who was alert, oriented, and had intact cognition according to her most recent assessment. The CNA opened the resident's drawers without first obtaining permission, searching for diapers, despite not being assigned to the resident that day. When the resident objected to the CNA's actions, the CNA responded by stating, "You don't own these diapers." The resident reported the incident to a licensed nurse at the nursing station. While the resident was making this report, the CNA followed and directed inappropriate and vulgar language at the resident, telling her to "shut the f** up." Interviews with facility staff, including the Director of Social Services, Director of Staff Development, and Director of Nursing, confirmed that staff are trained to respect resident rights and dignity, and that the CNA's actions were inconsistent with facility policy and expectations regarding resident privacy and respectful communication.
Failure to Notify and Document Bed Hold Status Upon Resident Transfer
Penalty
Summary
The facility failed to notify and confirm bed hold status with a resident's family representative upon the resident's transfer to an acute care hospital. The resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was transferred out of the facility, but there was no documentation indicating that the family representative was informed or that confirmation of the bed hold was obtained. Review of the Bed Hold Notification Informed Consent Form and interviews with staff, including the DON, Business Office Manager, and Licensed Nurses, confirmed that the required notification and documentation were not completed at the time of transfer. Multiple staff members acknowledged during interviews that the process for notifying and confirming bed hold with the family representative was not followed or documented. The facility's policy required written notice of the bed hold policy to be provided to the resident or representative at the time of transfer or within 24 hours in the case of emergency transfers. The lack of notification and documentation led to confusion for the family representative regarding bed hold payment.
Failure to Maintain Window Blinds in Resident Rooms
Penalty
Summary
The facility failed to maintain window blinds in good condition in five resident rooms on the first floor, as observed during a survey. Multiple rooms were found with missing blind slats, resulting in significant gaps that exposed residents to public view and allowed excess heat into the rooms. Specific observations included rooms with up to 22 missing slats, creating large open areas, and other rooms with varying numbers of missing slats, some of which were found on the floor. These deficiencies were directly observed by surveyors during their walkthrough of the facility. Interviews with staff revealed inconsistencies in the reporting and follow-up of maintenance issues. Certified Nursing Assistants and Registered Nurses indicated that they were expected to log broken items in a maintenance book, but some staff had not noticed or reported the missing blinds, even when aware of the issue for several weeks. The Maintenance Director confirmed that no recent maintenance requests for blinds had been received, and upon inspection, acknowledged the concerns with the missing slats. The Director of Nursing and the Administrator described the expected process for reporting and addressing maintenance issues, but the observations indicated that this process was not consistently followed, leading to the ongoing deficiency.
Failure to Refer Resident for Level II PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASARR) after the resident received new diagnoses of depression and bipolar disorder. According to facility policy, any resident with a newly evident or possible serious mental disorder is to be promptly referred to the state mental health authority for a Level II review. The resident in question was admitted with a history of hemiplegia and hemiparesis and later received diagnoses of depression and bipolar disorder, as documented in the medical record and Minimum Data Set (MDS), which also indicated moderate cognitive impairment. Despite these new mental health diagnoses, there was no evidence in the resident's medical record that a Level II PASARR was resubmitted as required. Interviews with the Assistant Director of Nursing (ADON), Social Services Director (SSD), and Director of Nursing (DON) confirmed that a new PASARR should have been completed and submitted when the new diagnoses were added. The facility's leadership staff acknowledged responsibility for the PASARR process and stated that the expectation was for a new screening to be submitted following the addition of a new mental illness diagnosis.
Failure to Resubmit PASARR Screening for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to resubmit a Level I preadmission screening and resident review (PASARR) to the appropriate state-designated authority for a resident with a history of serious mental illness. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, and depression, was readmitted to the facility and had ongoing care needs related to these conditions, as documented in the care plan and Minimum Data Set (MDS). A letter from the California Department of Health Care Services indicated that a Level II mental health evaluation was required but could not be completed because facility staff were unresponsive to multiple communication attempts within 48 hours. The letter instructed the facility to resubmit a new Level I screening. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, confirmed that the PASARR should have been resubmitted upon receipt of the state's notice. The ADON, who was responsible for the PASARR program, stated she had not seen the notice, and both the DON and Administrator acknowledged that the required resubmission did not occur as expected. The deficiency was identified for one of two sampled residents reviewed for PASARR compliance.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to post the actual hours worked by staff directly responsible for resident care for all 12 shifts reviewed. According to the facility's own policy, nurse staffing information, including actual hours worked by RNs, LPNs/LVNs, and CNAs, must be posted daily in a readable format. However, review of the Nurse Staff Projection documents for several days revealed that the actual hours worked were not indicated for all three shifts each day. This omission was confirmed through document review and staff interviews. Interviews with the Scheduler, Director of Staff Development (DSD), Director of Nursing (DON), and Administrator revealed that the responsibility for posting and updating nurse staffing data was not consistently fulfilled. The Scheduler admitted to sometimes forgetting to print or post the records, and the DSD acknowledged that the data sheets were not updated to reflect actual hours worked on multiple days. Both the DON and Administrator stated their expectations for accurate and updated postings, but the deficiency persisted, affecting all residents in the facility.
Failure to Offer Resident Choice During Shower Resulting in Psychological Distress
Penalty
Summary
Staff failed to honor a resident's right to self-determination and choice regarding personal care. On the morning of 3/21/25, two CNAs entered the room of a resident with spinal stenosis and discogenic pain and informed her she would be receiving a shower, without offering her a choice or seeking her consent. During the transfer from bed to shower, the resident experienced incontinence, requiring her to be cleaned and then placed in a Hoyer lift for transfer to the shower chair. The resident reported feeling upset and embarrassed during the incident, especially as the CNAs argued about operating the lift. A roommate, who was cognitively intact, witnessed the event and described the resident being yanked from bed and hoisted up. Interviews with staff confirmed that the resident was alert, oriented, and capable of expressing her preferences, and that it was important to explain care procedures to her beforehand. The Social Service Director also confirmed a complaint from the resident's son regarding the incident. Facility policy requires that residents be informed in advance of care, have the right to refuse or discontinue treatment, and that staff are educated on resident rights, including the right to choose schedules and activities. Despite these policies, the resident was not given the opportunity to exercise her right to refuse or choose her care at the time of the incident.
Failure to Maintain Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during the delivery of care. Two CNAs transferred a resident, who had diagnoses including spinal stenosis and discogenic pain, from her bed to a shower chair using a Hoyer lift. During this process, the resident's naked body was left exposed, as the privacy curtain between her and her roommate was pulled all the way back, allowing anyone in the room to view her. The roommate, who was cognitively intact, witnessed the incident and confirmed that no privacy was provided. The resident herself reported feeling upset and embarrassed, especially as she experienced incontinence during the transfer while the CNAs argued about how to operate the lift. The incident was further corroborated by interviews with the resident, her roommate, and the Social Service Director, who noted that the resident's son had also complained about the lack of privacy and rough handling. The Assistant Director of Nursing acknowledged that staff are expected to provide privacy and respect residents' dignity during care. The facility's policy requires staff to be educated on residents' rights, including the right to privacy and dignity, but this was not upheld in this instance.
Lack of CVC Competency and Training Among Nurses
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and training related to the care of Central Venous Catheter (CVC) sites for hemodialysis. This deficiency was identified for five out of seven licensed nurses. The lack of proper training and competencies had the potential to result in inaccurate assessments and delayed care for a resident with a CVC line. Interviews with the licensed nurses revealed that they did not receive formal training on CVC care, and some relied on verbal instructions or assumed the catheter's patency without proper assessment. Resident 1, who was admitted with End Stage Renal Disease, had a CVC line used for dialysis treatment. Despite this, several licensed nurses documented the presence of bruit and trill, which are not applicable to CVC lines but rather to arteriovenous fistulas. The Director of Nursing acknowledged the need for competencies and training in CVC care, and the facility was unable to provide a policy or procedure for CVC care, training, and skills checks.
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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 Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Knoll Specialized Care Facility | 1.3 mi | ★★★★★ | 18 | 0 |
| Santa Fe Post-acute | 1.9 mi | ★★★★★ | 11 | 1 |
| Pacific Villas Post Acute | 2 mi | — | 0 | 0 |
| La Paloma Healthcare Center | 2 mi | ★★★★★ | 0 | 0 |
| Bayshire Carlsbad | 3.9 mi | ★★★★★ | 1 | 0 |
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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.