The Vistas Assisted Living & Memory Care

Allegation investigated: Staff are administering oral liquids to a resident Staff are not keeping medications in their original bottle

On May 20, 2026, Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA Avila met with Nate Echols and explained the purpose of the visit. During the investigation process, interviews and records review were initiated. LPA investigated the allegation, “Staff are administering oral liquids to a resident.” Staff reported that medications are given to residents as perscribed in the physician orders. Staff reported that hospice residents are given medications as needed, which include liquid medications and staff follow physician orders in administering the medication. Staff reported a resident can refuse the medication and staff will then document the medication refusal and inform the resident's responsible party. -----Continued on LIC9099-C----- Unsubstantiated LPA investigated the allegation, “Staff are not keeping medications in their original bottle.” Staff reported that all staff adhere to their company policy regarding medications. Staff reported that in instances where residents are going on vacation, away from the facility with family, the original medications are signed out by family members and documented. Staff reported that a form is signed by both staff and family which documents the amount of medication being signed out and an audit is performed before and after the resident returns from their trip. Based on interviews conducted and record review, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 59-AS-20251117161325

Type of visit: Case Management - Incident

On November 13, 2025 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a case management visit and met with Nate Echols. Today’s visit is regarding an incident report that was submitted to licensing regarding an incident that occurred on August 22, 2025. It was reported that on August 22, 2025 at approximately 8:20 PM that R1 was found on the floor by R1's door after attempting to use a folding basket for support. R1 was not using their walker or pendant. EMS was called, and R1 was transported to the hospital. On August 23, 2025, the responsible party reported that R1 required surgery. R1 has a history of falling and has a walker but forgets to use it, so staff provides cuing. R1 did not have their pendant on hand as R1 forgets to wear it. The care plan was updated to reflect additional assistance needed with transferring and cuing. LPA obtained and reviewed documentation pertaining to R1. LPA will conduct a follow-up visit if deemed necessary. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Required - 1 Year

On November 13, 2025 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Nate Echols and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured within the required range. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but are not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. In the areas toured no immediate health, safety, or personal rights violations were observed. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of the Infection Control, Disaster prevention and last fire drill. Facility records are stored inaccessible to residents. The LPA reviewed eight (8) staff, and ten (10) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. No errors observed during the medication review. No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Required - 1 Year

On 11/14/2024 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Debra Wyman and explained the purpose of the visit. LPA Avila and Debry Wyman toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured at 114 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but are not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. In the areas toured no immediate health, safety, or personal rights violations were observed. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of the Infection Control, Disaster prevention and last fire drill. Facility records are stored inaccessible to residents. The LPA reviewed eight (8) staff, and eight (8) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Staff are not addressing residents who are exhibiting fall risk behaviors

On November 30, 2023 Licensing Program Analyst (LPA) Ivan Avila conducted an announced complaint investigation visit regarding the above allegation directed by the Department. LPA Avila met with Nate Echols and explained the reason for the visit. On 08/31/2023 R1 had a fall and sustained a skin tear on right hand and nosebleed. NOC shift notes stated that R1 was running down the halls and two falls were witnessed by staff. The first was caused by R1 running by double doors in the common area and ran into the wall. The second fall was due to R1 tripping over a recliner and hit their shoulder. Staff could not prevent R1 from falling but continued to monitor R1s activities. Continued on LIC9099C Unsubstantiated During the investigation process interviews and a records review was initiated. LPA Avila reviewed incident reports and physician report. Records reviewed indicated that resident falls are in large part due to physical and medical implications. LPA Avila reviewed facility records and each fall was documented and sent to the Department and Hospice Services. The facility has updated care plans for residents addressing fall behaviors. According to R1s physician’s report that was completed on 09/05/2023, R1 is ambulatory. R1 is not a fall risk. The physician report stated facility is to provide physical assistance to and from the dining room and or community activities as needed. Interviews that were conducted stated when residents would fall, staff immediately would assist residents. A minimum of two staff members would assist the resident who had fallen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of the report was provided to Nate Echols.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 59-AS-20230914092705

Allegation investigated: Facility staff are not providing adequate assistance to residents during meals

On November 30, 2023, Licensing Program Analyst (LPA) Ivan Avila conducted an announced complaint investigation visit regarding the above allegation directed by the Department. LPA Avila met with Nate Echols and explained the reason for the visit. During the investigation process interviews and a records review was initiated. LPA Avila reviewed R1s medical documentation and physician report. R1s physician report indicates that they do not need assistance with meals, but staff escorts R1 to every meal. According to R1’s physician’s report that was completed on 09/05/2023, R1 can feed self. R1 is ambulatory. The facility is to provide physical assistance to and from the dining room and or community activities as needed. LPA Avila reviewed staff schedules and sign in sheets and facility has sufficient staff. Continued on LIC9099C Unsubstantiated During the interview process it was stated that R1 would get up from the dinning table after staff would escort R1 to meals. R1 would get up and not sit still and staff redirected R1 to sit and eat. R1 would eat a couple bites of food then get up again and pace around the facility. Staff continued to redirect R1 to meals but R1 did not stay seated for long to eat. Staff would make R1 sandwiches so R1 could walk around and eat food. Staff also provided milk shakes to R1 and snacks if R1 did not finish their meal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of the report was provided to Nate Echols.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 59-AS-20230915104232

Type of visit: Required - 1 Year

On 11/30/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Nate Echols and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured at 117 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but at not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: Facility records are stored inaccessible to residents. The LPA reviewed seven (7) staff, and seven (7) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. No deficiencies during todays visit. Exit interview conducted and copy of the report was provided to Nate Echols.the state’s words, verbatim · CDSS document, Nov 30, 2023