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Complaint Investigation

New Vista Post-acute Care Center

June 24, 2024 · Los Angeles, CA · 1516 Sawtelle Blvd.
Citations 4
CMS Rating 2/5
Beds 116
Provider ID 055473
Healthcare Facility
New Vista Post-acute Care Center
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

NEW VISTA POST-ACUTE CARE CENTER in LOS ANGELES, CA — inspection on June 24, 2024.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

During an interview on 6/24/2024 at 1:15 p.m., LVN 2 stated LVN 2 was the charge nurse on 6/8/2024. LVN 2 stated Resident 1 smoked and required supervision when smoking. LVN 2 stated Resident 1 was alert and oriented to person, place, and time. LVN 2 stated Resident 2 was at risk for injury if unsupervised when smoking. LVN 2 stated the Activities Department provides cigarettes to residents. LVN 2 stated Resident 1 would go directly to Activities Department to get cigarettes and a lighter. LVN 2 stated the Activities Department would let the nurses know that Resident 1 was smoking. LVN 2 stated, No one from the Activities Department told me that [Resident 1] was outside smoking that day, 6/8/2024. LVN 2 stated on 6/8/2024 at around 2:00 p.m., LVN 1 wheeled Resident 1 in wc to the nurses' station and observed Resident 1 bleeding on the forehead. LVN 2 stated LVN 2 applied ice pack, called 911, and informed Resident 1's doctor and Residents 1's family. LVN 2 stated the facility transferred Resident 1 to the GACH on 6/8/2024.

During an interview on 6/24/2024 at 3:00 p.m., the Administrator (Adm) stated, Yes, this incident (between Resident 1 and Resident 2) could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times.

A review of facility's P&P titled Abuse Prevention/Investigation/Reporting and Resolution, effected 11/28/2026, indicated, The facility will protect the rights, safety, and wellbeing of each resident (regardless of physical and mental condition), for whom we provide care and treatment against any and all forms of physical . abuse, . or any treatment that would result in physical harm, pain, mental suffering .

The P&P further indicated Physical abuse includes assault . and hitting .

055473 06/24/2024

New Vista Post-Acute Care Center 1516 Sawtelle Blvd.

Los Angeles, CA 90025

the facility's smoking policy and procedure to explain the risks of unsafe smoking behavior.

During an interview on 6/24/2024 at 12:13 p.m., the Activity Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking.

The residents that requires supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke.

The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters.

The AD stated Resident 1 required supervision while smoking to prevent fights with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset.

During the same interview on 6/24/2024 at 12:13 p.m., the AD stated, Only myself and my assistant have the key to the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office.

Nursing staff do not have access to the activity office or any of the residents' cigarettes. I was not here for the fight between [Resident 1 and Resident 2] but my assistant was here.

Unfortunately, my assistant at the time no longer works here.

Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside.

055473

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055473 B.

Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd.

Los Angeles, CA 90025

During an interview on 6/24/2024 at 12:13 p.m., the Activities Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking.

The residents that require supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke.

The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters.

The AD stated Resident 1 required supervision while smoking to prevent Resident 1 from fighting with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset.

During an interview on 6/24/2024 at 12:20 p.m., the AD stated, Only myself and my assistant have the key to the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office.

Nursing staff do not have access to the activity office or any of the residents' cigarettes. I was not here for the fight between (Resident 1 and Resident 2) but my assistant was here.

Unfortunately, my assistant at the time no longer works here.

Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside.

055473

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055473 B.

Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd.

Los Angeles, CA 90025

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NEW VISTA POST-ACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.