Buena Vida Rehab and Nursing Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, and staff members indicated that there were staffing concerns in the facility. Additionally, the Payroll Based Journal Staffing Data Report for 01/01/2026-03/31/2026 triggered for Excessively Low Weekend Staffing, and a review of staffing from 01/01/2026-03/31/2026, and 05/01/2026-06/12/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents resided in a clean, comfortable, and homelike environment. This was evident in four (Floors 3, 4, 5, and 6) of seven resident care floors. Specifically, during observation, multiple areas throughout the facility were not clean or maintained in good repair, including damaged walls and wallpaper, peeling and chipped paint, stained ceilings, missing floor and shower tiles, damaged resident room fixtures, dirty surfaces, and deteriorated nurses' station furnishings

Inspectors wroteNumber of residents sampled: 38Number of residents cited: 3Based on observations, record review, and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one of one resident (Resident #13) reviewed for Dialysis. One of one resident (Resident #56) reviewed for Abuse and 0ne of five residents (Resident # 203) reviewed for Respiratory Care. Specifically, 1). A comprehensive care plan was not developed and implemented for Resident #13 who was receiving dialysis treatment, 2). A comprehensive care plan was not created for Resident #56 who was exhibiting self-injurious behavior, and 3). A comprehensive care plan was not created for Resident #203 who was receiving oxygen treatment.

Inspectors wroteNumber of residents sampled:38Number of residents cited: 4Based on record review and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident for one of five residents (Resident #8) reviewed for Unnecessary Medications, one of five residents (Resident #191) reviewed for Respiratory Care, one of one resident (Resident #56) reviewed for Abuse, and one of one resident (Resident #29) reviewed for Advance Directives out of a sample of 38 residents. Specifically, 1). The care plan related to Depression for Resident #8, 2). The Respiratory care plan for Resident #191, 3). The Abuse Care Plan for Resident #56, and 4). [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evidenced during the Kitchen task. Specifically, prepared and frozen foods were not labeled and dated appropriately.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the designated resident representative was notified of and involved in a significant medication change for one (Resident #56) of one resident reviewed for notification of change. Specifically, the facility decreased Resident #56's Seroquel dose from 25 milligram three times daily to 12.5 milligram three times daily on 01/26/2026 without documented notification to or consultation with the resident's representative.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for purposes other than the treatment of a medical symptom. This was evident in one (Resident #56) of one resident reviewed for physical restraints out of 38 total sampled residents. Specifically, Resident #56 was repeatedly observed sitting in the middle of their bed with legs hanging off the side of the bed between the elevated head and foot sections of the bed while the bed was placed against a wall. The facility lacked documentation supporting the medical necessity, informed consent, assessment, or ongoing reevaluation of the bed's placement against the wall.

Inspectors wroteBased on record review and interviews, the facility did not ensure that all alleged violations involving abuse or neglect, including injuries of unknown origin, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than twenty four hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the New York State Department of Health. This was evident in two (Residents #56 and #241) of seven residents investigated for accidents. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident received dental care in a timely manner. This was evident for one of two residents (Resident #128) reviewed for Dental out of a sample of 38 residents. Specifically, a Nursing Note dated 05/08/2026 documented that Resident #128 required a dental consultation, and there was no documented evidence that Resident #128 was seen and evaluated timely by a dentist.

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage and refuse were disposed of properly. This was evident during multiple observations of the garbage disposal area. Specifically, garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests.

Inspectors wroteBased on observation, interviews, and record reviews conducted during an Abbreviated Survey (NY00317501), the facility failed to ensure that a resident who is fed by enteral means receives the appropriate care and services to prevent complications of enteral feeding. This was evident for one out of four residents (Resident #1) sampled for nutrition. Specifically, Resident #1 experienced persisting diarrhea from March 2023 to October 2023 while receiving tube feedings and experienced a significant weight loss of over 20 percent. There was no documented evidence that additional medical follow-up was attempted when the facility was unable to identify a cause for the persistent diarrhea or that increased weight monitoring was implemented when Resident #1 experienced a significant weight loss.

Inspectors wroteBased on interviews and record review conducted during the recertification and complaint (NY00310615) survey from 2/21/2024 to 2/28/2024, the facility did not ensure all alleged violations involving injuries of unknown source, were reported immediately to the New York State Department of Health, but not later than 2 hours after the allegation is made. This was evident for 1 (Resident #24) out of 4 residents reviewed for Abuse out of 35 total sampled residents. Specifically, the facility did not report Resident #24's dislocated right shoulder of unknown origin within 2 hours of the occurrence.

Inspectors wroteBased on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, 1) oxygen tubing was observed touching the floor; 2) a catheter bag was observed on the floor; 3) Alcohol Based Hand Sanitizers (ABHR) were used after expiration date; and 4) staff did not ensure residents' hands were sanitized prior to meals. This was evident for 2 of 4 residents reviewed for Respiratory Care (Resident # 33 and Resident # 52), 1 of 3 residents reviewed for Urinary Catheter (Resident # 52), 5 of 6 units observed for Infection Control (Unit #2, 3, 4, 5, & 7) and 1 of 6 units observed for Dining (Unit #7).

Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Complaint survey, the facility did not ensure that person-centered care plans were developed to address a resident's medical needs. Specifically, a comprehensive care plan (CCP) related to anticoagulant (AC) use was not developed for a resident receiving Eliquis. This was evident for 1 of 7 residents reviewed for Unnecessary Medication. (Resident #35).

Inspectors wroteBased on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that all medications and biologicals were labeled in accordance with currently accepted pharmaceutical principles and practices. Specifically, resident metered dose inhalers did not have a medication label that includes the resident's name, medication name, prescribed dose, strength, and route of administration. This was evident for 3 resident inhalers on 1 of 6 units observed for Medication Storage (Unit 3).