Buena Vida Nursing & Rehab Odessa

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure there was a care plan in place for Resident#1's dialysis needs. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's glimepiride (an oral medication used to manage blood sugar levels in adults with type 2 diabetes). The medication was not available according to the signed MARThis deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that could be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 3 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for using a Geri chair for mobility for Resident #3. This failure could place the residents at risk of a decreased quality of life, and not having their needs met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 1 resident reviewed for feeding tube management (Resident #1). The facility failed to ensure Resident #1 had a physician order for the volume, frequency, and type of flush to administer via the gastrostomy feeding tube (a surgically created abdominal opening into the stomach for the purpose of administering feedings). The facility failed to ensure Resident #1 had a physician order on the frequency of cleaning and the care of the site on the gastrostomy feeding tube. These failures placed the resident at risk for tube obstruction, malfunction, dysfunction, abdominal discomfort, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medication carts (#1, #2 and #3) reviewed for medication storage. The nurse medication carts used for halls 100, 200, 300 and 400 had an insulin vial that had been opened but had no open date. There were insulin pens that had expired since being opened as indicated by the manufacturer's instructions. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #81) reviewed for transfers in that: CNA D and LVN C transferred Resident #81 from her bed to her wheelchair by grabbing her from the back of her pants and her under arms. These failures could put residents at risk of accidents and injuries which could result in a reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #7) of 3 residents reviewed for infection control. LVN D failed to use PPE when she administered Resident #7's medication via his IV central line (A central line is a catheter placed into a large vein. A central line provides access to a person's blood supply, which allows the patient to receive medications, fluids or additional blood). This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision to prevent accidents for 5 (Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5) of 11 Residents reviewed for residents having lighters. The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5 were not in possession of an unauthorized lighter. 1 of the 5 residents (Resident #1) used a lighter to burn the gauze bandage, which was secured to her right foot, resulting in second degree burns to her right foot. An Immediate Jeopardy (IJ) situation was identified on 4.4.25. The IJ template was provided to the facility on 4.4.25 at 3:10pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care to Resident #1 on 02/25/2025. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 3 of 12 residents (Residents #24, #69, and #43) reviewed for pharmacy services and medication administration. The facility failed to administer blood pressure medications as prescribed for Residents #24 and #69. The facility failed to ensure Resident #43 had parameters outlining when to hold her short-acting insulin. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #19) of two residents reviewed for accidents hazards and supervision. The facility failed to ensure that Resident #19's wheelchair was properly padded to prevent injury to the resident's legs while she used it to move around the facility. This failure could lead to injury and possible infection to the resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #79) of 3 residents reviewed for infection control. CNA A failed to wash his hands and change his gloves after they became contaminated during incontinent care while assisting Resident #79. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had the right to be free from any physical restraints not required to treat the resident's medical symptoms for two (Residents #11 & #55) of three residents reviewed for physical restraints. 1. Residents #11 & #55 had bolsters (scoop mattresses) on their beds without physician's orders that the bolsters were to treat a medical condition and no assessments used to determine they were the least restrictive measure. There was no restraint-focused assessment completed for Residents #11 & #55 regarding whether the bolsters constituted restraints for them. 2. There was no consent documentation from Resident #11 or Resident #55 or their resident representatives for bolsters to be placed on their beds. [...]

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. A bag of rolls was past the expiration date. The lids and handles of two food storage bins were covered with an accumulation of brown-tinged grime. This failure could place residents at risk of food borne illness.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program by referring all residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for 1 (Resident #23) of 3 resident's reviewed for PASARR coordination. The facility failed to refer Resident #23 to the local authority for Level 1 PASARR screening after he was given a new diagnosis of schizoaffective disorder. This failure could place residents at risk of not receiving specialized and/or habilitation services as needed to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #22 & #46) of 12 residents observed for oxygen management. Residents #22 & #46, who used on oxygen, did not have oxygen sign posted outside their bedrooms. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.