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.

• Immediate jeopardy, isolatedF689Oct 3, 2025

  Based 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). […]

• Immediate jeopardy, isolatedF607Aug 22, 2022

  Based on observation, interview and record review the facility failed to ensure their abuse policy and procedure was implemented when one of three sampled residents (Resident 1) was found with facial bruises (bluish, black skin discoloration) and stated Someone a man had kept on punching or hitting me , when asked regarding the bruises on her face. The facility failed to report to the Department not later than 2 hours upon knowledge of the incident, failed to interview staff and other possible witnesses of the incident, and protect the resident from the alleged perpetrator (someone -man) while the facility pursues their investigation. […]

• Actual harm, isolatedF656Oct 20, 2025

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812Jan 17, 2025

  Based 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. Findings included: A facility policy titled, Personnel Sanitation Standards, effective 02/2024, revealed, 1. In addition to employee personnel policies, food and dining personnel will be required to adhere to the following sanitary standards: a. hair must be restrained or covered (via hat or hair net). During an observation on 01/15/2025 at 11:11 AM, [NAME] #5 prepared sandwiches and did not wear facial restraint. […]

• No harm, potential for more than minimal, patternF908Oct 3, 2025

  Based 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. […]