Buena Vista Healthcare

Inspectors wroteBased on observation and interview, the facility failed to maintain 1 of 1 ice machines (Ice Machine 1) in a sanitary manner. This failure placed the residents at risk of consuming contaminated ice and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medications (medications that affect the mind, mood, and emotions) prior to administration of the first dose, for 1 of 5 sampled residents (Resident 2), reviewed for unnecessary medications. This failure placed the resident at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care-planned goals and interventions related to peripheral edema (swelling of the lower legs, ankles and feet due to fluid buildup caused by poor circulation, heart, liver, or kidney conditions or certain medications) for 2 of 2 sampled residents (Residents 5 and 44) reviewed. This failure placed the residents at risk for possible worsening health conditions and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the bowel protocol for 1 of 5 sampled residents (Resident 2) reviewed for constipation. This failure put the residents at risk of discomfort and health consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement resident specific interventions to prevent pressure ulcer/injuries for 1 of 4 sampled residents (Resident 2) reviewed for pressure ulcers. This failure placed residents at risk for development of pressure ulcers, medical complications, and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a urinary catheter system (a tube inserted into the bladder that drained urine into a collection bag) was maintained in a clean manner for 1 of 1 sampled residents (Resident 22) reviewed. This failure placed the resident at risk for infection and injury if the collection bag and tubing were damaged.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive plan to prevent the growth of water-borne viruses and bacteria such as Legionella (bacteria that caused a potentially fatal form of pneumonia when water mist or vapor that contained the bacteria was inhaled) for the Water Management Plans reviewed. This failure placed residents at risk of illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the immediate environment of 5 of 6 sampled residents (Residents 18, 16, 24, 3, and 21) reviewed for environment, was free from visible clinical information prior to assessing if it violated the resident's privacy.

Inspectors wroteBased on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (Residents 16 and 24) reviewed for hospitalizations. This failure placed the residents at risk for a disruptive and ineffective transition from the facility to the hospital setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the care plans for 2 of 12 sampled residents (Residents 16 and 24) whose care plans were reviewed. This failure placed the residents at risk for inadequate care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming for 1 of 3 sampled residents (Resident 35), reviewed for activities of daily living (ADLs). This failure placed the resident at risk for poor personal hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate hearing services for 1 of 1 sampled resident (Resident 24) reviewed for communication. This failure placed the resident at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when staff were observed serving food without using appropriate hand hygiene for 1 of 3 dining observations. Staff were also observed carrying cups with bare hands touching the rims of drinking surfaces. This failure increased the resident's risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent pressure ulcer/injuries for 1 of 3 sampled residents (8). Resident 8 experienced harm when they developed avoidable pressure ulcers. This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to consistently implement effective preventative measures for falls, by evaluating the effectiveness of current interventions and the need for increased supervision for 4 of 4 sampled residents (Residents 31, 33, 36, and 51), reviewed for accidents. Resident 51 experienced harm when they sustained a hip fracture requiring hospital treatment and Resident 36 experienced a pattern of frequent falls. These failures placed residents at risk for repeat falls, major injury, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record reviewthe facility failed to provide cueing and meal assistance, monitor for significant weight loss, and risk of skin integrity for nutrition for 1 of 1 sampled residents (29). The resident experienced harm when they had an unplanned severe weight loss, nutritional decline, and breakdown of skin integrity with wound development. This failure placed other residents at risk for unplanned weight loss, medical complications, and unmet care needs. Findings icluded . <Resident 29> Review of the 03/25/2024 significant change assessment, showed Resident 29 had diagnoses which included stroke, anemia, and ataxia (impaired coordination). [...]

Inspectors wroteBased on interview and record review the facility failed to implement bowel management protocol when indicated for 2 of 5 sampled residents (Resident 26 and 31), reviewed for constipation. In addition, the facility failed to monitor and implement interventions for edema (swelling) management for 1 of 3 sampled residents (31), reviewed for edema. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions, cleaned mechanical lifts after usage, and performed hand hygiene when indicated during the meal service and wound care. These failures placed residents at risk of transmission of communicable diseases and/or healthcare associated diseases, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and care plan for safe self-medication administration for 1of 1 sampled residents (Resident 28), reviewed for medication administration. This failure placed residents at risk of medication errors, adverse side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistive cups as care planned for 1 of 3 sampled residents (Resident 17) reviewed for activities of daily living (ADL's). This failure placed the resident at risk for continued swallowing difficulties and decreased fluid intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided for 2 of 3 sampled residents (Resident 17 and 29) reviewed for activities of daily living (ADLs). Specifically, two residents used their fingers to help scoop food onto their eating utensils and to pick up food from their plates and their nails had dark matter under them. This failure placed the residents at risk of contracting bacterial and diarrheal illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 1 of 1 sampled residents (Resident 26) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff had the proper qualifications. Failure to ensure the dietary manager had the proper certification placed all residents at risk for nutritional deficits, unmet nutritional needs, and diminshed quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain appropriate dishwasher temperatures, date and dispose of expired foods and failed to prepare food in a sanitary manner. These failures placed the residents at risk for food borne illnesses and decreased quality of life.