Buena Vista Care Center

Inspectors wroteBased on interview and record review, the facility staff failed to follow physician orders related to the monitoring of blood glucose levels for one of 24 sampled residents (Resident 11) when there were no documentation to indicate if blood sugar testing was done as ordered on days missed. This failure has the potential to lead to medication error that can lead to severe hypoglycemia (low blood sugar). During a review of the facility's Face Sheet (admission record), Resident 11 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus([DM] abnormal blood sugar). During a review of Resident 11's Physician Orders (PO), dated 10/6/25, the PO indicated to administer Insulin Glargine solostar pen-injection 100 unit/ml (milliliter). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policies regarding the storage of pharmaceutical products when a medication storage room was equipped with a single-door refrigerator/freezer unit, rather than a pharmacy-grade, two door unit with separate freezer compartment and door, when combine. This failure has the potential to lead to inconsistent temperatures and compromise the potency of stored medications when inuse. During an observation of the medication storage room in Station A on 4/8/26 at 9:14 a.m., a refrigerator used for medication storage had a single door for both freezer and refrigerator. The freezer was observed to have ice buildup. During the interview on 4/9/26 at 2:38 p.m. with the administrator (ADM), ADM stated that the facility does not store medication in the freezer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the dietary prescription of 1 unsampled resident (Resident 129). This failure had the potential for Resident 129 to have health complications. During a review of the facility's Face Sheet (admission record), Resident 129 was admitted to the facility on [DATE] with diagnoses that included Acute Kidney Failure, unspecified (a sudden loss of kidney function). During a concurrent observation and interview on 4/8/26 at 6:18 a.m., with the Dietary Manager (DM) during tray line, the meal ticket for Resident 129 indicated in part Regular, Fluid Restriction 1500 ml Thin Liquids and Renal Diet. The tray was observed with a salt packet, this observation was validated by the DM and stated will double check the dietary prescription. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety is maintained when an outdated bottle of juice was left in the refrigerator and spoiled produce were left for use and not discarded. This failure had the potential to expose residents to foodborne illnesses (diseases that are caused by eating contaminated food). During a concurrent observation and interview in the facility kitchen on 4/8/26 at 6:07 a.m. with the Dietary Manager (DM), a bottle of juice was observed in the refrigerator that had a best by date of 4/1/26. During a concurrent observation and interview on 4/8/26 at 6:11 a.m. at the facility kitchen with the DM, cucumbers were noted to have had mold and to be mushy (an unpleasant, stale, or damp smell caused by mold or mildew). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses (LNs) completed wound assessments and developed a care plan that included treatment and monitoring of a surgical incision for 1 of three sampled residents (Resident 1) upon admission to the facility. This failure had the potential to result in delayed healing and infection to Resident 1's surgical wound. During a review of Resident 1's History and Physical (H&P), dated 12/10/24, the H&P indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included post fall, had a subdural hematoma (collection of blood between brain and outer surface), and status post craniotomy (surgical procedure that temporarily removes part of skull). During a review of Resident 1's Progress Notes (PN), dated 12/6/24, this indicated, Body assessment done upon admission and noted the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) in one of two sampled residents (Resident 1) with known alcohol dependence (a chronic disease in which a person craves alcoholic drinks and is unable to control his or her drinking), alcohol abuse and opioid dependence (the persistent urge to use legal and illegal drugs that reduce the intensity of pain signals). These failures had the potential of Resident 1 not having the coping mechanisms and support needed to prevent the use of illicit drug use (drugs that are illegal to produce, sell, or possess, or use in an illegal or inappropriate manner) and resulted in Resident 1 having a heroin (highly addictive, illegal opioid drug with high potential for abuse and no accepted medical use) drug overdose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for one of three sampled residents (Resident 1) when Resident 1, who was assessed as an elopement risk and provided with a Wander Guard (device that alarms), left the facility unmonitored. This failure placed Resident 1 at risk for injury or death. During a review of Resident 1's admission Record (AR), dated 10/2/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that includes unspecified Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors) and anxiety disorder (a feeling of fear, dread, and uneasiness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform daily functional testing of the Wander Guard system (an alert system worn on a resident's wrist that activates an audible alarm when passing doors equipped with sensors to prevent unsafe wandering) per manufacturer's instruction for use. This failure had the potential for seven residents using Wander Guard devices to elope from the facility without being detected. During the interview on 10/2/25 at 4:30 p.m. with licensed nurse (LN 2), LN 2 verified that Wander Guard devices are checked for functionality by nursing staff weekly every Thursday. During an interview on 10/2/25 at 5:00 p.m. with Director of Nursing (DON), DON stated there are seven (7) residents using Wander Guard devices and confirmed that the devices were checked weekly and not checked daily with results documented in the medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided for one of two sampled residents (Resident 2). This failure had the potential for Resident 2 and other residents to have unrelieved and/or uncontrollable pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff verified the accuracy of a physician's order in one of 2 residents' medical record (Resident 1). Resident 1 had an order of NPO (nothing by mouth) and another order was to give medication by mouth. This failure had the potential to place Resident 1 at risk for medication related adverse events and complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a restroom in good repair for one of two sampled residents (Resident 1). This failure had the potential to deny Resident 1 with a homelike environment.

Inspectors wroteBased on record review and interview the facility failed to implement care plan interventions for 1. Feeding assistance needs for one of three sampled residents (Resident 1). 2. Pressure injury care and prevention for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience weight loss and progression of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to position a wound vacuum pump in accordance with manufacturer guidance for 1 sampled Resident (Resident 1). This failure had the potential to cause a tripping hazard to residents, staff, or visitors as well as a risk of disconnecting the device upon tripping.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure hair restraints were worn for dietary staff during meal service. This deficient practice had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess 1 (Resident #129) of 24 sampled residents for the ability to self-administer their medication(s).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #16) of 24 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resubmit a new Level I screening when 1 (Resident #22) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR) remained in the facility on the 31st day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly for 1 (Resident #129) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) after a fall incident for one of two sampled residents (Resident 1). This failure had the potential to eliminate RP's participation in the development and implementation of Resident 1's person-centered plan of care.

Inspectors wroteBased on record review and interview, the facility failed to assist one of two sampled residents (Resident 1) in making an outside appointment, per a prescriber's order. This facility failure had the potential to result in a delay of care for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a system for a full and complete accounting and management of personal funds entrusted to the facility, for one of three sampled residents (Resident 1). This failure had the potential for misappropriation of Resident 1's personal funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan regarding impaired skin integrity was implemented for the care of one of two sampled residents (Resident 1) when: 1. Resident 1 had a fall on 11/6/23, and acquired a skin tear to the right knee, and a wound assessment was not done. 2. Resident 1 had a fall on 11/14/23, the wound condition had changed, and a wound assessment was not done. These failures may have contributed to Resident 1 receiving antibiotics at the hospital when being treated for right lower leg cellulitis (bacterial skin infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately maintain two shower rooms in good repair. This facility failure had the potential for residents not to experience a homelike environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) were reflected as signed and ordered in the POLST by the attending physician on to the residents electronic medical record (EMR) for five of 24 sampled residents (Residents 95,42,25, and 47). This failure had the potential to cause a delay or violate resident's rights as to wishes on administering life-sustaining treatments during an emergency because of inaccurate or inconsistent documentation in the EMR.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when: 1. Contact time (time product should stay wet) of disinfectant/cleaner could not be verbalized by staff 2. Staff did not change gloves after cleaning dirty surfaces in the resident's room before getting supplies from the clean supply cart 3. Disinfectant/cleaner was contaminated prior to use in residents' rooms 4. Hand hygiene was not performed 5. Disposable gown reused in laundry 6. Dirty scissors were placed in clean treatment cart These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was in place for a sanitary, free of insects and pests environment when: 1. Black bugs (fruit flies) were flying in Resident 47's room 2. Spiders were found in Resident 72's room 3. Black bugs (fruit flies) were flying in several residents Rooms (Residents 54, 10, 49, and 309). This failure placed these residents at risk of vector-borne diseases (diseases that result from an infection transmitted to humans by pests and insects such as cockroaches, mosquitos, flies and maggots, fleas, spiders, and rodents).

Inspectors wroteBased on observation and interview, the facility failed to ensure residents rooms were free from broken ,non functional items (torn window screen , peeling off wallpapers , baseboards, broken window metal handle) for two sampled residents (Resident 72 and Resident 47) This failure had the potential to be safety risks that can affect the residents overall health and ability to function.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a care plan regarding ambulation was implemented for the care of one of 24 sampled residents (Resident 95). This failure placed Resident 95 at risk for decreased mobility with the potential to decline in ambulation skill.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bottle of Tramadol (a narcotic pain medication), was disposed as required by law. This failure had the potential to lead to drug diversion (when prescription medicines are obtained or used illegally).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. A thermometer was in one of two medication refrigerators' freezers (medication room A 1's small refrigerator) sampled. 2. No expired medications were inside two of two medication carts sampled (cart A 1 and B 2) a. A bubble pack (individualized medication pack) of Amlodipine (medication to lower blood pressure) expired 12/21/21 b. A bubble pack of Prednisone (medication that reduces swelling in the body, and also suppresses your immune system) expired 2/28/22 c. A bubble pack of Metoclopramide (medication for nausea) expired 1/31/22 d. A bottle of liquid Acetaminophen (Tylenol) expired 1/31/22 e. A bottle of Probiotic capsules (good bacteria to aid in digestive health) expired 5/30/20 f. A bottle of Prostat (liquid protein medical food) expired 2/22 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences as assessed and ordered were implemented in three of three residents (Residents 57, 92, and 249) when: 1. Residents 57 and 92's tray ticket /card stated No Salt but the meal trays served were with salt. 2. Resident 249's tray ticket /card indicated No bread and No beans but the resident was served with a meal tray containing bread and beans. These failures have the potential to result in medical condition changes secondary to not following physician assessed orders pertaining to residents diet.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and sanitary kitchen was maintained when two kitchen fans located right above a food/drinks preparation area were with dust and debris. This failure had the potential for residents' food/drinks to be contaminated resulting to gastrointestinal or other medical issues.