Buena Vista Care Center

In the surveyor’s words

From the most serious findings on record at Buena Vista Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 1, 2024

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Food preparation surfaces were not sanitized. 3. Fresh lettuce was not washed prior to use. 4. A sanitizing solution was not available for manual dishwashing in emergency situations. 5. Gloves were not used appropriately. 6. Facial hair was not covered. 7. Two of 14 kitchen employees had drinking cups or personal drinking containers in the kitchen. 8. […]

• No harm, potential for more than minimal, patternF812Dec 18, 2025

  Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment was kept in sanitary condition. * The facility failed to ensure the kitchen equipment was cleaned properly. * The facility failed to ensure the hair restraints were worn. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 of 89 residents consumed food prepared in the facility's kitchen. 1. […]

• No harm, potential for more than minimal, patternF880Dec 18, 2025

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility's Infection Prevention and Control Surveillance Logs for 2025 were incomplete and inaccurate. * The facility's Infection Control Committee Meeting Minutes and data presented were inaccurate for 2025. * LVN 4 failed to ensure the GT syringe was properly cleaned prior to storage. * The facility failed to ensure N95 masks stored in Medication Cart C were not expired. * LVN 1 failed to perform hand hygiene during the blood glucose check monitoring for Residents 64 and 77. […]

• No harm, potential for more than minimal, patternF881Dec 18, 2025

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up with the physician regarding the residents on the antibiotic therapy who did not have true infections based on the McGeer's criteria listed in the Infection Prevention and Control Surveillance Logs for 2025 and for three nonsampled residents (Residents 46, 47, and 65) * Residents 46, 47, and 65's physicians' were not notified to reevaluate their antibiotics when their infections did not meet the McGeer's criteria. […]

• No harm, potential for more than minimal, patternF565Nov 1, 2024

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to effectively respond to the repeated concerns of cold food brought up in the monthly Resident Council meetings. This failure resulted in the Resident Councils concerns of cold meals being an ongoing issue, putting the residents at risk of undesirable outcomes. Findings: Review of the facility's P&P titled Resident Council, revised February 2021 showed the purpose of Resident Council is for residents to discuss concerns and suggestions for improvement. The facility department related to any issues will be responsible for addressing the items of concern. […]